Axial computed tomography of pilon fractures

Total fractures of the tibial pilon

Complete fractures of the tibial pilon are rare and their treatment difficult. The pathophysiology includes three groups: (A) high-energy trauma (motor vehicle injuries), with severe articular and soft tissue lesions, (B) rotation trauma, (skiing accidents), with modest articular and soft tissue damage, and (C) low-energy trauma in elderly people. These three groups occasion very different problems and complications. In emergency situations, these fractures should be stabilized, most often using external fixation to restore length and prepare definitive fixation. The second stage can be applied once soft tissue healing is achieved. Two methods are discussed: internal plating and definitive external fixation. The first goal of treatment is to restore the articular surface, although this does not always prevent secondary arthritis. The second is to restore correct positioning of the foot as regard to the leg. The complication rate is high. Neither of the two fixation techniques has proven to be more effective. In group B, the two methods are similar, but external fixation seems to be safer in group A.

Ipsilateral intact fibula as a predictor of tibial plafond fracture pattern and severity

BACKGROUND

The objective of this study was to determine whether there is a difference in fracture pattern and severity of comminution between tibial plafond fractures with and without associated fibular fractures using computed tomography (CT). We hypothesized that the presence of an intact fibula was predictive of increased tibial plafond fracture severity.

METHODS

This was a case control, radiographic review performed at a single level I university trauma center. Between November 2007 and July 2011, 104 patients with 107 operatively treated tibial pilon fractures and preoperative CT scans were identified: 70 patients with 71 tibial plafond fractures had associated fibular fractures, and 34 patients with 36 tibial plafond fractures had intact fibulas. Four criteria were compared between the 2 groups: AO/OTA classification of distal tibia fractures, Topliss coronal and sagittal fracture pattern classification, plafond region of greatest comminution, and degree of proximal extension of fracture line.

RESULTS

The intact fibula group had greater percentages of AO/OTA classification B2 type (5.5 vs 0, P = .046) and B3 type (52.8 vs 28.2, P = .013). Conversely, the percentage of AO/OTA classification C3 type was greater in the fractured fibula group (53.5 vs 30.6, P = .025). Evaluation using the Topliss sagittal and coronal classifications revealed no difference between the 2 groups (P = .226). Central and lateral regions of the plafond were the most common areas of comminution in fractured fibula pilons (32% and 31%, respectively). The lateral region of the plafond was the most common area of comminution in intact fibula pilon fractures (42%). There was no statistically significant difference (P = .71) in degree of proximal extension of fracture line between the 2 groups.

CONCLUSIONS

Tibial plafond fractures with intact fibulas were more commonly associated with AO/OTA classification B-type patterns, whereas those with fractured fibulas were more commonly associated with C-type patterns. An intact fibula may be predictive of less comminution of the plafond. The lateral and central regions of the plafond were the most common areas of comminution in tibial plafond fractures, regardless of fibular status.

LEVEL OF EVIDENCE

Level III, case control study.

The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures

OBJECTIVES

The purpose of this investigation is to define the location and frequency of tibia pilon fracture lines and impaction injury for the most severe variety (OTA/AO type 43C3).

PATIENTS/METHODS

Using axial computed tomography scan images, 38 consecutive OTA/AO type 43C3 fractures treated by a single surgeon were analyzed. For each fracture, a map of the fracture lines and zones of comminution was drawn. Each map was digitized and graphically superimposed to create a compilation of fracture lines and zones of comminution. Based on this compilation, major and minor fracture lines were identified and fracture patterns were defined. Specifically, a basic Y pattern, constant across all patients, was identified where the stem of the Y went into the fibula incisura. All other fracture lines were considered secondary and these defined the comminution.

RESULTS

One hundred percent of major fracture lines involved the tibiofibular joint and all exited medially in 2 general zones, anterior and posterior to the medial malleolus best described as a Y-shaped pattern. Therefore, 3 main fragments existed in every single case. Comminution was present in 36 of 38 (95%) cases, and it was predominantly located centrally and in the anterolateral quarter.

CONCLUSIONS

There is a consistent fracture pattern underlying the majority of OTA/AO type 43C3 pilon fractures that could be defined as 3 main fragments: anterior, medial, and posterior. These result from a major fracture line extending from the fibular incisura and exiting anterior and posterior to the medial malleolus. The comminution commonly distinguishing pilon fractures occurs from secondary fracture lines through the apex of the plafond and in the anterolateral region. Knowledge of this constant pattern should influence surgical approaches and possibly implant design.

Effect of computerized tomography on classification and treatment plan for patellar fractures

OBJECTIVE

To evaluate the impact of computerized tomography (CT) scan on both fracture classification and surgical planning of patellar fractures.

DESIGN

Prospective study.

SETTING

Academic level I trauma center.

PATIENTS AND METHODS

Four fellowship-trained orthopaedic trauma surgeons analyzed radiographs of 41 patellar fractures. Each fracture was classified (OTA/AO classification), and a treatment plan was developed using plain radiographs alone. The process was repeated (4-6 weeks later) with addition of CT scan. After 12 months, the 2-step analysis was repeated and interobserver reliability and intraobserver reproducibility were assessed.

RESULTS

Suboptimal intra- and interobserver reliability was found for the surgical plan and classification using the OTA/AO system, despite the addition of a CT scan. After addition of CT, reviewers modified the classification in 66% of cases and treatment plan in 49%. CT frequently demonstrated a distinctive and severely comminuted distal pole fracture; this fracture pattern was present in 88% of cases and was unappreciated on plain radiographs in 44% of those cases. This pattern is unaccounted for by the present OTA/AO classification.

CONCLUSIONS

CT facilitates improved delineation of patellar fracture patterns. Understanding the distal pole fracture pattern is fundamental in choosing a fixation construct. A fracture-specific classification system, based on CT scans, should be developed.

Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures

BACKGROUND

There remains no consensus regarding the role of computed tomography (CT) scans in preoperative planning for malleolar ankle fractures. The aim of this study was to determine the role of preoperative CT scans on operative planning in these fractures.

METHODS

A retrospective analysis was performed on 100 consecutive patients treated at our institution for malleolar ankle fractures (AO type 44) with both preoperative radiographs and CT scans. Six study participants reviewed available radiographs and formulated an operative (or nonoperative) plan including positioning, operative approach, and fixation. Participants then analyzed CT scans of the same fractures, deciding whether (and how) they would alter operative strategy. Characteristics of fractures and radiographs were correlated with changes in operative strategy.

RESULTS

Operative strategy was notably changed in 24% of cases after CT review, with strong intraclass correlation (0.733). Common changes included alterations in medial malleolar (21%) or posterior malleolar (15%) fixation and fixation of an occult anterolateral plafond fracture (9%). Notable predictors of changes in operative strategy included trimalleolar over unimalleolar fractures (29% vs 10% rate of change), preoperative dislocation over no dislocation (31% vs 20%), the presence of only radiographs with overlying plaster versus fractures with at least 1 set of radiographs without plaster (25% vs 14%), and suprasyndesmotic versus trans- and infra-syndesmotic fractures (40% vs 20% and 4%, respectively).

CONCLUSIONS

CT scans may be useful adjuncts in preoperative planning for malleolar ankle fractures, most notably in fracture dislocations, cases in which all available radiographs are obscured by plaster, trimalleolar fractures, and suprasyndesmotic fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The operative treatment of complex pilon fractures: A strategy of soft tissue control

BACKGROUND

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. The soft tissue injury and handling of the soft tissue envelope are crucial in pilon fracture outcomes. The purpose of this study was to evaluate the early rate of complications using the strategy of "soft tissue control" for operative treatment of complex pilon fractures.

MATERIALS AND METHODS

36 complex pilon fractures were treated with the "soft tissue control" strategy. Patients followed the standard staged protocol, anterolateral approach to the distal tibia, the "no-touch" technique and incisional negative pressure wound therapy for pilon fractures. Patients were examined clinically at 2-3 weeks and then 8 weeks for complications associated with the surgical technique.

RESULTS

All fractures were AO/OTA (Orthopaedic Trauma Association) type C fractures (61% C3, 22% C2 and 16% C1). Only one patient developed superficial infection and resolved with antibiotics and local wound care. None developed deep infection.

CONCLUSIONS

The strategy of soft tissue control for treatment of pilon fractures resulted in relatively low incidence of early wound complications in patients with complex pilon fractures.

Decisions and staging leading to definitive open management of pilon fractures: where have we come from and where are we now?

Historically, the treatment and outcomes related to pilon fractures have been variable despite anatomical reduction and fixation. However, with the advent of newer implant technologies, improved surgical techniques, and the management via a staged protocol, results have indicated encouraging clinical outcomes with minimization of postoperative complications. This review focuses and outlines the current strategies, decision-making processes, and definitive treatment options regarding the notoriously difficult to treat pilon fracture.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures

OBJECTIVE

Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures.

DESIGN

Prospective clinical cohort.

SETTING

A Level I trauma and tertiary referral center.

PATIENTS/PARTICIPANTS

From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months).

INTERVENTION

All patients were treated with open reduction and internal fixation for their pilon fractures.

MAIN OUTCOME MEASUREMENTS

Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications.

RESULTS

There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group.

CONCLUSIONS

The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

Pilon fractures

The nature of the pilon fracture has caused evolution of treatment methods and its historically high rate of complication and poor outcome continue to direct choice of treatment. Attention to the delicate soft tissue envelope surrounding the ankle and recognition of the severity of the initial injury is crucial to ensure a satisfactory outcome and to minimize complications. Understanding the importance of staging surgical interventions will help to improve outcomes, but even optimal treatment may result in less than satisfactory results.

Pilon fractures: advances in surgical management

Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft-tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft-tissue envelope is paramount to optimizing outcomes. In persons with soft-tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft-tissue management, such as negative-pressure dressings, may be helpful in preventing complications.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

The pilon fracture

Treatment of the ‘pilon’ fracture provides one of the greatest challenges to orthopaedic surgeons today. The force required to fracture the distal tibia can lead to complex fracture configurations and significant soft tissue compromise that challenge subsequent repair. High complication rates have encouraged extensive research over decades into an operative method that limits the insult to the surrounding soft tissue envelope whilst maintaining the stability of the fixation obtained. Two main techniques of fixation that meet such criteria have evolved more than others namely, open reduction and internal fixation (ORIF — two-staged protocol) and external fixation (ankle sparing hybrid fixation). Advances in these techniques have seen a significant reduction in the rate of catastrophic complications such as amputation, osteomyelitis and arthrodesis. The legacy of the pilon fracture, however, is such that it is hard to decide which treatment method is best and indeed severe fractures (AO classification type C2 or 3 or Reudi and Allgower type III) are better treated with primary arthrodesis and even amputation in some cases. Both methods have their drawbacks. A high prevalence of pin tract infections and possibly inadequate reduction may occur in some cases treated with external fixators. There is considerable variability of outcome with the two-staged protocol depending on the patients treated, the judgement and skill of the surgeon operating and risk of soft tissue compromise. The two-staged protocol seems to have a greater following and seems on the surface to get over many typical complications. No one treatment method is best for all fractures; in fact both are equally good for simpler fractures. It is their outcome in treating severe fractures that will determine which of the two methods is best and which could be adequately tested with a randomised controlled trial.

Temporizing external fixation of the lower extremity: a survey of the orthopaedic trauma association membership

This study examined the opinions of practicing traumatologists to aid in the initial treatment of complicated lower extremity fractures in accordance with current staged protocols. A 40-question online survey of the Orthopaedic Trauma Association (OTA) membership was administered from November 2008 to February 2009. The survey investigated surgeons' preferences regarding general principles and routine management of joint-spanning lower extremity external fixators, as well as favored knee- and ankle-spanning constructs and conditions of definitive surgical reconstruction. Data were collected using a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1). Responses were given numerical weight in descending order (scoring 5-1) and were reported as straight percentages and with a weighted mean called the rating average.Responses were received from half of the OTA membership. Among the strongest preferences (rating average >4) were for obtaining a computed tomography (CT) scan as part of prereconstruction planning (4.8) and obtaining that CT scan after joint-spanning external fixation was applied (4.6). Restoration of length as the most important part of limb realignment at the time of temporizing external fixator application (4.3), the use of soft tissue protection during pin application (4.4), and avoiding overlap of pin sites with a plate at the time of reconstruction (4.3) were highly favored. Survey respondents treated a sizable volume of periarticular lower extremity injuries with temporizing external fixation and staged reconstruction. This consolidation of trends and preferences for constructing and using temporizing external fixation for complex lower extremity injuries hopefully will aid in the treatment of these difficult fractures.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Fractures of the tibial plafond

High-energy fractures of the tibial plafond are a lifechanging event for the patient. Currently, open reduction and internal fixation (ORIF) appears to offer the best chance for obtaining and maintaining anatomic articular reduction and axial alignment to union. Definitive ORIF should be performed in a staged fashion to allow adequate resolution of the associated soft tissue injury. A preoperative plan is essential to a successful outcome and it must include a strategy to access and stabilize the articular and nonarticular components of the injury.

High-energy foot and ankle trauma: principles for formulating an individualized care plan

Care of the patient with high-energy foot and ankle trauma requires an individualized care plan. Staged treatment respecting the traumatized soft tissue envelope is often advisable. Wound care is a priority, and the vacuum-assisted closure dressing serves an integral role. Before definitive reconstruction, the surgeon needs to develop a treatment plan designed to match the unique personality of the patient and injury. Amputation is considered a rational treatment option for the patient with severe injury and poor host biology. Despite the most appropriate management, many severe foot and ankle injuries have a guarded prognosis.

Virtual 3D planning of acetabular fracture reduction

Displaced acetabular fractures are best treated with open reduction to achieve anatomic reduction and maximize the chance of a good functional outcome. Because of the anatomic complexity and often limited visualization, fracture reduction can be difficult. Virtual planning software can allow the surgeon to understand the fracture morphology and to rehearse reduction maneuvers. The purpose of this study was to determine the effect of a novel virtual fracture reduction module on time and accuracy of reduction. Four acetabular fracture patterns were created in synthetic pelves, which were implanted with fiducial markers and were registered with CT scan. Ten surgeons used virtual fracture reduction software or conventional 2D planning methods and immediately reduced the fractures blindly in a viscous gel medium. 3D imaging was again performed and the accuracy of reduction was assessed. The average malreduction was significantly improved following planning with the virtual software compared to the standard technique. The time taken for reduction was also significantly less for two of the four fracture patterns. Virtual software may be useful for visualizing and planning treatment of fractures of the acetabulum, potentially leading to more accurate and efficient reductions, and may also be an effective educational tool.

An update on the management of high-energy pilon fractures

High energy pilon fractures present a unique challenge to the patient and orthopaedic surgeon. Care for the soft tissue envelope is as important as management of this articular fracture. This article reviews the fundamental principles for treatment of the patient with severe pilon fracture. Staged operative care is emphasised to prevent wound and infectious complications which have historically plagued pilon fracture surgery. New innovations directed at improving results are discussed including biological planting and wound care using the vacuum assisted closure device. Lastly, validated outcomes are presented which highlight the severity of these injuries despite optimal care.

Vascular abnormalities as assessed with CT angiography in high-energy tibial plafond fractures

OBJECTIVE

The purpose of this study was to examine the results of computed tomography angiography (CTA) obtained in patients with high-energy tibial plafond fractures and assess if the information gleaned from CTA could be useful to the treating orthopedic surgeon.

DESIGN

Consecutive patient series.

SETTING

Level 2 trauma center.

PATIENTS

Consecutive patients treated between October 1, 2004 and June 31, 2006 for high-energy injury of the tibial plafond according to a protocol of early temporizing external fixation, CT, and elevation, followed by delayed reconstruction of the tibial plafond.

INTERVENTION

Addition of angiography to CT scan (CTA) in treatment protocol.

MAIN OUTCOME MEASUREMENTS

CTA abnormalities were identified and categorized to define the pattern of arterial lesions present. Characteristics of patients, injuries, treatments, and complications were evaluated and related to CTA findings.

RESULTS

CTA was performed at an average of 3 days postinjury in 25 consecutive patients treated for high-energy tibial plafond fractures. Abnormalities of the arterial tree of the leg were seen in 13 of 25 (52%) patients. One patient had 2 of 3 vessels notably injured. Fourteen arteries showed acute changes at the level of injury and 1 showed significant chronic atherosclerotic disease at the trifurcation. Acute arterial abnormalities included 7 arteries with complete occlusion, 2 with partial occlusion/diminished flow, and 5 with normal flow but with anatomic disturbances (4 tenting over and 1 entrapped by fracture fragments). Open fractures were associated with arterial abnormalities (P<0.05), but no other characteristics correlated with arterial injury. No patients had dye reactions or other problems relating to CTA. Patients with CTA-diagnosed vascular abnormalities were treated with more minimally invasive surgery than those without at the discretion of the surgeon, and no patients with vascular abnormalities had wound problems or infection.

CONCLUSIONS

In more than half of high-energy tibial plafond fractures, CTA identified significant abnormalities to the arterial tree of the distal leg. These injuries most commonly involved the anterior tibial artery and included a variety of lesions. CTA appears to be a safe and potentially useful tool for the assessment and preoperative planning of high-energy tibial plafond fractures.

The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing

Perhaps the most important advancement in the surgical treatment of high-energy pilon fractures has been the recognition of the need to delay primary surgery. However, at open reduction internal fixation an adequate incision must be made to clearly visualize the articular surface in an attempt to restore intraarticular anatomy. This article illustrates our extensile approach and its effect on soft-tissue healing. The approach allows complete access to the ankle joint to achieve reduction and fixation of the articular surface, as far medially or laterally as is necessary. In addition, it allows for easy placement of plates medially, laterally, or anteriorly. For fractures extending more proximally, plates can be placed subcutaneously from distal to proximal through the open incision.

The surgical management of high- and low-energy tibial plafond fractures: A combination of internal and external fixation devices

Fractures of the distal tibial articular surface are complex injuries that can destroy the ankle joint. This article discusses the mechanism of injury, classifications and historical means of treating these fractures, the authors' approach to treating low- and high-energy pilon fractures, prognosis, and complications.

Orthopedic pitfalls in the ED: tibial plafond fractures

Fractures of the tibial plafond, or distal tibial articular surface, are usually associated with a high-force mechanism, which frequently can involve associated injuries and prolonged disability. Because of distracting injury and variations in clinical findings, tibial plafond fractures may be initially missed or misdiagnosed. This review examines the clinical presentation, diagnostic techniques, and management of tibial plafond fractures applicable to the emergency practitioner.

Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity

Complex intra-articular and periarticular fractures of the lower extremity are challenging injuries to treat. Recently, the concept of utilizing a staged approach with temporary external fixation, a delay to allow soft-tissue healing followed by open reduction and internal fixation, has gained popularity. Historically high complication rates appear to be significantly improved with this strategy. Temporary external fixation is also useful in other settings, such as in the initial management of polytraumatized patients with multiple complex fractures, augmentation of internal fixation in osteoporotic bone, etc. This article reviews current indications, techniques, potential complications, and results of temporary external fixation for complex fractures of the lower extremity.

Pilon fractures: assessment and treatment

The treatment of high-energy intra-articular fractures of the tibial plafond involves many potential complications. A protocol has been developed. This protocol recognizes the importance of the surrounding soft tissues and is based on sound principles and thorough clinical experience. This article discusses this protocol and its use and explains why it is now more widely accepted.

The treatment of pilon fractures

Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.

The adolescent pilon fracture: management and outcome

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.

Postero-medio-anterior approach of the ankle for the pilon fracture

A good view of the operative field is important for better reduction and fixation in surgical treatment of fractures. The exposure of the ankle joint for the pilon fracture is commonly through the anterior approach, or combined with the medical approach. But sometimes it is still difficult to have complete viewing of the articular surface and to apply internal fixation by that approach. In recent years, we developed a "postero-medio-anterior" approach of the ankle joint by one incision. This approach provides an excellent exposure of the anterior, medial and posterior aspects of the ankle joint with a clear view of the articular surface. In our 45 cases of pilon fracture during 1991 to 1995, there was no incisional injury to the neurovascular bundle. Superficial wound edge necrosis was noted in two cases which healed later without further procedure. Therefore, we recommend this approach as a simple and reliable incision for open reduction of pilon fractures.