![]() ![]() Type A are extra-articular fractures, Type B are partial articular involving a single column, and Type C are complete articular fractures, all with subtypes differentiated on fracture pattern, amount of comminution, and presence or location of impacted articular fragments. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) offers a more comprehensive classification system dividing up pilon fractures into Types A, B, and C with subsequent subtypes ( Table 1). For example, an intact fibula can necessitate medial column instability and varus deformity while the opposite is true when the fibula is involved. Evaluation of the fibula can provide further information on the stability of the injury. ![]() Likewise, when exerted lateral to the center of the ankle, valgus configuration results. When the force is predominantly midline or medial to the ankle, the fracture will result in a varus deformity. Neutral foot positioning results in a purely vertical vector engaging the entire articular surface, resulting in both anterior and posterior column fractures with variable varus and valgus angulation. The opposite is true when the foot is dorsiflexed, the energy is transmitted through the anterior region. When the foot is plantar-flexed at the time of injury, forces are directed into the posterior portion of the articular surface leading to impaction and posterior talar displacement. Typically, the talus is driven into the plafond during a high-energy axial load. ![]() The fracture pattern and soft tissue injury is dictated by the positioning of the foot at the time of injury. While rotational pilon fractures still occur, the vast majority are the result of higher-energy mechanisms such as falls from a great height and motor vehicle accidents. 6 Thus, this review offers an update to surgical management and treatment of pilon fractures with special considerations taken during the decision-making process. Even after successful treatment of these injuries, complications in the postoperative period, such as infection, wound dehiscence, non-union, malunion, and post-traumatic osteoarthritis are difficult to avoid without proper technique. 2 – 7 The importance of addressing all components of the skeletal trauma cannot be overstated. 1 Compared to the fractures originally described and treated by Rüedi and Allgöwer, pilon fractures globally represent higher-energy mechanisms that often involve substantial articular impaction and severe soft tissue injury due to an axial load rather than the relatively low energy rotational mechanism originally studied. These injuries compile <1% of all lower extremity fractures and achieving good clinical outcomes is both challenging and complex. Later termed “plafond” meaning “ceiling” in the French language, equating the distal tibial articular surface as the ceiling of the ankle joint. The term “pilon” is derived from the French language, meaning pestle, resembling a pharmacist’s pestle when paralleled to the distal tibial metaphysis. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.įirst described by French radiologist Destot in 1911, pilon fractures are defined as injuries that involve the articular weight-bearing surface of the distal tibia. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. ![]() External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. Pilon fractures include a wide range of complexity. ![]()
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