Evolution in Management of Tibial Pilon Fractures

Abstract

Purpose of review: Tibial plafond, or pilon, fractures can be some of the most difficult fractures to manage. As they are often associated with high-energy trauma, both the soft tissue involvement and the comminuted fracture pattern pose challenges to fixation. Furthermore, the complex anatomy and trauma to the cartilage at the time of injury predispose pilon fractures to poor functional outcomes and high rates of posttraumatic arthritis. This review will discuss the recent developments in the treatment of tibial pilon fractures.

Recent findings: Historically, surgical management of pilon fractures has been associated with high rates of complications, including wound complications, infections, nonunions, and even the need for amputation. In response, staged protocols were created. However, recent studies have called this into question, demonstrating low wound complications with early definitive fixation. Additional studies are evaluating adjuvants to minimize wound complications, including the use of vancomycin powder and oxygen supplementation, while another study challenges the 7-cm myth regarding the distance needed between skin incisions. Additional research has been focused on alternative methods of managing these complex, and sometimes non-reconstructable, injuries with the use of external fixation, minimally invasive internal fixation, and primary arthrodesis. Tibial pilon fractures remain difficult to treat for even the most skilled orthopedic trauma surgeons. With improvements in surgical techniques and implants, complication rates have declined and outcomes have improved; however, the overall prognosis for these injuries often remains poor.

Keywords: Distal tibia fracture; Intra-articular fracture; Pilon fracture; Plafond fracture.

Fig. 1

A closed fracture that was treated in a staged manner with an ankle spanning external fixator. Skin wrinkles returned 7 days post injury (copyright by AO Foundation, Switzerland)

Fig. 2

Various intervals that can be used to approach the distal tibia. The image red line represents our preferred approach when access is needed to both the anterolateral and posterolateral aspects of the tibial plafond. An incision is made along the anterior border of the fibula, and dissection was carried out both anterior and posterior to the fibula, providing access to the fibula and anterolateral tibia

Fig. 3

An anterolateral approach to the distal tibia. Note the full-thickness soft tissue flaps created to access the fracture site. Minimal retraction was used to expose the fracture for plate application. Here, distal K-wires used for temporary stabilization of the articular segments also act as retractors to minimize soft tissue handling

Fig. 4

Radiographs and CT scan demonstrate a partial articular pilon fracture. Dual incisions with anterolateral and medial approaches were used to build back to an intact posterior column

Fig. 5

A complete articular tibial plafond fracture managed using staged protocol with an ankle spanning external fixator to temporize the soft tissues. The fracture was subsequently stabilized with an anterolateral distal tibia locking plate and supplemental fixation of the metaphyseal fragment. Additionally, a subcutaneous low-profile medial anti-glide plate was utilized to support the medial column that was not captured by the anterolateral plate

Fig. 6

The sequence of reduction and fixation for a C-type pilon fracture, from left to right. First, the articular surface was reduced and provisionally stabilized with K-wires and an independent lag screw. Length and alignment were then re-established by reduction of the lateral column. This was accomplished with reduction and stabilization of the fibula, as well as the lateral plafond. Lastly, the medial column was restored and buttressed using a low-profile scallop plate