Pilon Fractures - Sally Tennant 8/4/2002

PILON= French "To ram or hammer"

Involves articular surface, metaphysis and occasionally extends into diaphysis

Usually from high energy vertical compression forces eg fall from height, RTA

Lower energy injuries eg from ski-ing-often involve torsional component

Dorsiflexion of ankle during impaction produces anterior articular impaction and comminution

Plantarflexion produces posterior articular damage

Classifications

Ruedi & Allgower -vertical compression fractures

Type 1              Undisplaced cleavage

Type 2              Cleavage fracture lines with displacement of articular surface

Type 3              Metaphyseal and articular comminution

Diagram p2057 Campbells

Mast, Spiegel & Pappas

Type 1              Rotational injury with vertical load producing malleolar fracture

                        Supination-ER with vertical loading

Type 2              Spiral extension type

Type 3              Vertical compression (see above)

AO classification

Type A             Extra-articular distal tibial

Type B              Partial articular

Type C              Complete metaphyseal fracture with articular involvement

Prognostic value of classification systems-little displacement and comminution associated with better functional results and fewer complications

MANAGEMENT

POP

Traction

Lag screws

ORIF

Ex-fix    -Half pin spanning ankle

            -Articulated half pin allowing ankle ROM

            -Hybrid fixators (do not span ankle jt)

Primary arthrodesis

Factors

High/low energy

Fracture type

Ipsilateral fractures of foot and tibia

ST injury

Patient characteristics, eg DM, PVD, Smoking, alcohol

Undisplaced

Operative or non-operative

These are the only fractures where cast alone suitable

Displaced

Surgery better than conservative management

Ruedi & Allgower-ORIF 1960s

Stabilise fibula with plate

Medial buttress plate on tibia with bone graft

With increasing numbers of open and high energy injuries, recent series report fewer successful results and higher complication rates especially for Ruedi & Allgower type 3 and AO Type C3 and open fractures

Eg infection rates 12.5-37% in type 3 fractures

26% needing later arthrodesis

Therefore ORIF now only recommended for:

Low energy injuries

Large displaced fragments

Little comminution

No diaphyseal extension

Minimal swelling

Good ST envelope

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