Plafond Fractures of the Tibial · Objectives nDefine pilon fractures nClassify pilon fractures...
Transcript of Plafond Fractures of the Tibial · Objectives nDefine pilon fractures nClassify pilon fractures...
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Fractures of the Tibial Plafond
Dan HorwitzGeisinger
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Objectives
n Define pilon fracturesn Classify pilon fracturesn Discuss treatment protocols
n Staged managementn Definitive options – focus on ORIF
n Highlight complications
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Definitions
Articular injury Usually axial load injury
Frequently high energy Can be low energy or rotational
Soft tissue injury
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No Returns or Second Chances NO Returns or Second Chances
HandleWith Care
Caution! Open carefully, intra-articular fracture inside
47 c
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Not An Ankle Fracture!
Ankle fracture Low energy Rotational Minimal comminution Possibility of articular involvement�Posterior malleolus�Large medial malleolus
Relatively little soft tissue injury
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Epidemiology
Reasonably Rare 1% of all lower extremity injuries 10% of all tibia fractures
Bilateral up to 8% Open in 10 – 50% Compartment syndrome 0 -5% Other fractures 27 – 50%
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AO/OTA fracture classification
A3
B3
C3
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Soft Tissue Evaulation
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History of Treatment
Immediate Immediate ORIFORIF
External External FixatorsFixators
Staged Staged ReconstructionReconstruction
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What Do We Do Now?
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Staged Protocols
Sirkin, 1999• 56 Pilons• Immediate fibular ORIF
with ankle spanning external fixation
• Average 12.7 - 14 days to ORIF• 1.8% wound dehiscence• 3.6% infection
Patterson, 1999• 22 C3 Pilons• Average 24 days to ORIF• 73% Anatomical reductions
• No Infections
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Staged Protocol
Early• Trans-articular
external fixation• Fix fibula…????• Allow soft tissue
stabilization
Late• Definitive
Articular reconstruction
• Remove fixator
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Pilon Fractures Staged Fixation
Initial ex-fix +/- ORIF fibula
Definitive Fixation
WhatWhatHappens?Happens?
Soft Tissue Soft Tissue ImprovesImproves
Partial HealingPartial Healing
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Poor Timing
Poor OutcomePoor Outcome
Soft tissue must be ready for surgical insult
GuaranteesWagner, Unfallchir, 1986 Mast, CORR 1988Trumble, JOT 1992 Wyrsch, JBJS 1996Helfet, CORR 1994
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Stage 1 Goals
• Restoration of skeletal length and alignment
• Span joint and allow soft tissues to stabilize
• Distraction across ankle joint
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Stage 2 Goals• Avoid complications• Anatomic restoration
of joint• Stable fixation to
allow motion• Healed anatomically
aligned limb
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Stage 2 Goals• Multiple methods
• Ex-fix (definitive)• Hybrid fixation• ORIF
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Stage 2 Goals -Strategy
• Multiple Incision Options• Based on soft
tissues• Articular Involvement• Multiple small
(percutaneous)
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Articular Injury• 3 Major Fragments
Anterolateral Articular (Chaput)
Medial Malleolus
Posterior Articular (Volkmann’s)
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AnteromedialStage 2 Goals -Strategy
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Anterolateral
Stage 2 Goals -Strategy
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AnteriorStage 2 Goals -Strategy
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Anterior “workhorse incision”Stage 2 Goals -Strategy
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What about the “7cm” Rule ?• Multiple smaller
approaches• Posterolateral fibular
approach and fixation• Anterolateral approach
for articular surface and metadiaphyseal fixation with submuscular plate
• Percutaneous medial buttress plate
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• Begin with Posterolateral Fragment
• Fix posteromedial to posterolateral
• Reduce central impaction• Reduce Medial and
Anterolateral fragments• Provisional wire fixation• Lag Screw Fixation• Fix articular block to
diaphysis
Stage 2 Goals -Strategy
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n Always fix the fibula first…???n Always fix the fibula…?n When do you graft..??
n When you need it for structural support or if you have stripped ST more than you want and are worried about biology
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Post-op Protocol• Immobilization until sutures out (2-4 wks)
• Cam walker until able to keep foot at neutral
• NWB for 10-12 weeks
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Outcomes• Patients get better for up to 2.4
years (perception)–Ankle scores improve with time
• Increase arthritis with time–Radiographic
Marsh, JBJS 2003
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Outcomes• Negative long term impact on
function• Limitation in recreation
–Running (27/31)• Half change jobs
Marsh, JBJS 2003
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CASE
21 yo male fall while rock climbing
Closed injury
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Case
n32 yo male in MVAnClosed isolated injury
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Case
nI don’t like this one….
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Outcomes• 50% don’t return to work• Significant impact on overall
function• Bad injuries
Pollack, JBJS 2003
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•
Salvage?
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PILONn More complex…n Simplistic approach – Willie Sutton rulen VERY systematic approach – back to front
or medial to lateraln Choose the best implant – sometimes
smaller is bettern Never never never hesitate to span and
wait…rare exception has early ORIF
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Summary
• Difficult fractures• No single
treatment method• Staged protocol• Patience
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Summary
• Biological exposure & fixation
• Anatomic restoration of the articular surface
• Rigid fixation to allow early motion