The pilon tibiale fracture Thomas Beck Spitalzentrum Oberwallis OTC Trauma course september 2017 xxx
I have no financial relationships with commercial entities that produce healthcare related products.
please describe this pilon fracture
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!
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!!
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
Initial Assessment / emergency treatment Distal: - Functional and neurovascular status - Active & passiv motion - Palpate pulses / Index - Test sensibility - CAVE: Compartment syndrome 7
Initial Assessment / emergency treatment Diagnostic: - X-ray: 8
Initial Assessment / emergency treatment
Initial Assessment / emergency treatment
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:
Initial assesment / emergency treatment The real truth of this injury: Courtesy Ch. Sommer
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!
Initial Assessment / emergency treatment In pilon fracture treatment soft tissue care has the highest and first priority.
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
First stage surgery - SPAN SCAN PLAN
First stage surgery Working horse:
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
First stage surgery Spanning externeal fixator - Restore rotation, axis and length across the joint
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
CT tells a lot more than plain X-ray CT reconstructions give far more informations 3D reconsturctions are possible Exact messurements are possible
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
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
Set of circumstances: - Analysis of fracture pattern - Soft tissue condition - Patient factors - My own surgical skills
Pilon fracture: - High energy axial trauma on distal tibia - avulsion, bending or torsion rare - The bone fails under axial loading with articular involvement
Rotational Forces = Malleolar Fx Axial Load = Pilon Fx
Medial column Lateral column Fibula Syndesmosis Articular surface
Anterior column Posterior column Articular surface
C C C T C C Central Loading Eccentric Loading
INJURY PATTERNS: FX IN VALGUS Most frequent Lateral column fails in compression Spike on compression side Fibula + / - Medial column in distraction
INJURY PATTERNS: FX IN VARUS Medial column fails in compression Lateral column in distraction Fibula + / -
INJURY PATTERNS: CENTRAL LOADING No angulation Both columns fail in compression Central comminution Rare syndesmotic injury (check Mortise widening)
INJURY PATTERNS: SAGITTAL
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
Start with the spike (and a key fragment)
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
Posterior access: - lateral or medial
plate on the compression side
Stabilize additional columns (MIPO if possible)
The problem of choosing the right access! - Depending on soft tissue injury - Depending on injury mechanism - Depending on key fragments
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
Timing for definitive treatment: - When the skin is wrinkling!
Problems not discussed : - Open pilon fractures - Soft tissue injury requiring coverage by plastic surgery - Bony defects requiring bone grafts
Complications: - infection - Osteoarthritis - Malunion - nonunion
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