The pilon tibiale fracture

Transcription

1 The pilon tibiale fracture Thomas Beck Spitalzentrum Oberwallis OTC Trauma course september 2017 xxx

2 I have no financial relationships with commercial entities that produce healthcare related products.

3 please describe this pilon fracture

4 Goals of pilon fracture treatment Avoid soft tissue injury complications Achieve union and stability Restore function A pilon fracture is a high energy severe soft tissue injury with a broken joint!

5 Principles of pilon tibiale fracture treatment Initial assessment / emergency treatment Your job!! First stage surgery May be your job!! Plan definitive care Definitive treatment Not yet your job!!

6 Initial Assessment / emergency treatment life before limb - Follow the ATLS principles: - A: Airway and C-spine - B: Breathing - C: Circulation & Haemorrhage control - D: Disability - E: Exposure - Secondary survey 6

7 Initial Assessment / emergency treatment Distal: - Functional and neurovascular status - Active & passiv motion - Palpate pulses / Index - Test sensibility - CAVE: Compartment syndrome 7

8 Initial Assessment / emergency treatment Diagnostic: - X-ray: 8

9 Initial Assessment / emergency treatment

10 Initial Assessment / emergency treatment

11 Initial Assessment / emergency treatment Classification does not tell us the truth: - Says nothing about mechanism and the injury forces - Says nothing about the dislocation - And there ist still one thing missing:

12 Initial assesment / emergency treatment The real truth of this injury: Courtesy Ch. Sommer

13 Initial Assessment / emergency treatment A fracture: - Is static once happened - Is easy assessed - Is easy quantified and classified A soft tissue injury - Is dynamic - Accumulative - Difficult to assess, especially in early stages!

14 Initial Assessment / emergency treatment In pilon fracture treatment soft tissue care has the highest and first priority.

15 First stage surgery Goals of early soft tissue injury treatment - Recognition!! - Treat urgent situation: - Open fractures - Vascular injuries - Compartment syndrome - Prevent additional damage: - Stabilize - Evaluate - Delay definite treatment

16 First stage surgery - SPAN SCAN PLAN

17 First stage surgery Working horse:

18 First stage surgery Spanning external fixator - Stabilitiy to restore limb closer to its normal anatomy - Faster resolution of soft-tissue swelling, than casts - Provides better access to wound care and compartment monitoring - Even mobilization is possible - Buy time for better planning and soft tissue management

19 First stage surgery Spanning externeal fixator - Restore rotation, axis and length across the joint

20 First stage surgery Think about pin placement: - Interference with CT - Far away from OR-field to keep option for plating - Allow access to the wounds - Keep the simple Fixation of the fibula: - Good soft tissue condition - Only if anatomically reduced and fixed - Interference with second stage surgery access

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22 CT tells a lot more than plain X-ray CT reconstructions give far more informations 3D reconsturctions are possible Exact messurements are possible

23 CT-scans in addition to plain X-ray affect fracture classification in >25% and thus the surgical plan Degree of articular depression is often underapperciated on plain radiographs Identification of keyfragments is possible

24 The Plan: - Intended method of getting from one set of circumstances to another. - Movement from the present situation to the achievment of one or more goals - Anticipate of problems and difficulties

25 Set of circumstances: - Analysis of fracture pattern - Soft tissue condition - Patient factors - My own surgical skills

26 Pilon fracture: - High energy axial trauma on distal tibia - avulsion, bending or torsion rare - The bone fails under axial loading with articular involvement

27 Rotational Forces = Malleolar Fx Axial Load = Pilon Fx

28 Medial column Lateral column Fibula Syndesmosis Articular surface

29 Anterior column Posterior column Articular surface

30 C C C T C C Central Loading Eccentric Loading

31 INJURY PATTERNS: FX IN VALGUS Most frequent Lateral column fails in compression Spike on compression side Fibula + / - Medial column in distraction

32 INJURY PATTERNS: FX IN VARUS Medial column fails in compression Lateral column in distraction Fibula + / -

33 INJURY PATTERNS: CENTRAL LOADING No angulation Both columns fail in compression Central comminution Rare syndesmotic injury (check Mortise widening)

34 INJURY PATTERNS: SAGITTAL

35 Understanding fracture mechanism is a guide to treatment: - Restore length - Look lateral: Fibula simple or komplex - CAVE: bad fibula fixation leeds to bad tibia fixation

36 Start with the spike (and a key fragment)

37 Continue with articular surface - Try to bring a C-type fracture to a B-type fracture - Try to fix «the rest» against a intact column - Reduce joint fragments to the talus - Don t forget to reduce the talus first - Fill up the defect with «bone» - Temporary k-wire fixation of articular fragments - Sometimes an additional posterior access is necessary

38 Posterior access: - lateral or medial

39 plate on the compression side

40 Stabilize additional columns (MIPO if possible)

41 The problem of choosing the right access! - Depending on soft tissue injury - Depending on injury mechanism - Depending on key fragments

42 Antero - lateral Fibula Lateral column articular surface (medial column) Antero medial Medial column articular surface (lateral column) Postero lateral Fibula Posterior column Articular surface Postero - medial Medial column Posterior column articular surface

43 Timing for definitive treatment: - When the skin is wrinkling!

44 Problems not discussed : - Open pilon fractures - Soft tissue injury requiring coverage by plastic surgery - Bony defects requiring bone grafts

45 Complications: - infection - Osteoarthritis - Malunion - nonunion

46 summary A pilon tibale fracture is a severe soft tissue injury with a fractured joint Axial trauma with articular surface fracture SPAN: Externel fixator is the working horse in first stage surgery SCAN: 3D CT scan is essential for understanding the fracture pattern and thus PLAN the definitive operative treatment TIMING is essentiel