Distal tibial fractures

Mark Lee AOT Basic Principles Course

Learning outcomes

Describe the anatomical characteristics of the distal tibia and

•

why injuries of the distal tibia are unique

Define fractures requiring absolute stability and those

•

amenable to relative stability, focusing on different fracture

patterns

Recall techniques of internal fixation that avoid soft-tissue

•

damage while preserving blood supply to the bone

Describe the role of the fibula in the operative treatment of

•

distal tibial fractures

Objectives

By the end of this talk you should be able to:

Appreciate the significance of this injury

•

Understand the fracture characteristics

•

Describe the treatment principles

•

Avoid the potential complications

•
Description
•“Pilon”—Noun (Fr): pestle, an instrument used
for crushing/pounding

•Results from axial load

•This is not just a torsional injury

Ankle versus pilon

•Low energy •High energy

•Minor articular damage •Major articular damage

•Minimal swelling •Significant swelling

 Respect the pilon
Complications:
•

Wound breakdown
Infection

Malunion

Nonunion

Arthritis

Stiffness

Amputation
Problem: soft-tissue injury!
 Evaluation
History
•

 Associated injuries

Physical Exam
•

Focus on soft-tissue envelope

Careful neurological exam

X-rays
•

CT scan after reduction

•
Fracture classification

AO/OTA Fracture and

•

Dislocation
Classification, 43

A: Extraarticular
•

B: Partial articular
•

C: Complete articular
•
 Goals of treatment

•Anatomic articular
reduction
•Restoration of length,

alignment, rotation
•Reattachment of joint to

metadiaphysis
•Sufficient stability to

allow for early joint

motion
Surgical indications
•Articular incongruity

•Joint instability

•Limb malalignment
History

• Ruedi TP et al (Injury. 1969;2:92–99)

ORIF yields excellent results

• Kellam JF et al (J Trauma. 1979;19:593–601)

ORIF has high complication rates

Patterson MJ/ Sirkin M (J Orthop Trauma. 1999;13:85–91)

Staged ORIF minimizes complications
 Staged protocols

Sirkin, 1999 Patterson, 1999

56 Pilons 22 C3 Pilons
Immediate fibular ORIF with Average 24 days to ORIF
ankle spanning external fixation 73% Anatomic reductions
Average 12.7 - 14 days to ORIF
No Infections
1.8% wound dehiscence
3.6% infection

Open and Closed Fractures

Staged protocol

1. Temporary limb stabilization

2. Await resolution of soft-tissue swelling

3. Study the injury

4. Staged reconstruction

Sirkin et al (J Orthop Trauma. 1999;13:78–84)

1. Temporary limb stabilization
Restore lateral column length/stability
•

Fibular reduction
Posterolateral incision

Creates a pillar to build pilon back to

Fibular reduction can be difficult!

•

Williams et al, JOT 1998

 1. Temporary limb stabilization
•Restore medial column
length/stability
Spanning ankle external
fixation
Anticipate future surgical


approach
 Anticipate implant position
 1. Temporary limb stabilization
•Restore medial column
length/stability
Spanning ankle external
fixation
Anticipate future surgical


approach
 Anticipate implant position
Frame application
Medial Delta
 2. Wait on soft-tissue swelling

•Wait
•Wait some more

•And some more

Timing priority: soft tissues

Caution Proceed!
Surgical timing
•Correct timing critical
•Patience!

•Rarely day 1–6

•Often day 14–21

•Wrinkles
While you’re waiting...

•Get additional information

•Think!

•Prepare a preoperative plan!

 3. Study the injury
Carefully study using:
•

CT scan
Axial, sagittal, coronal
reconstructions
Understand injury

Develop surgical tactic

Tornetta and Gorup, CORR, 1993

 Pilon map: axial CT scan
Anterior

•Experience
Patterns emerge
Fragment recognition
Medial Lateral
•Chaput, Medial, Volkmann
Zones of impaction

Posterior

Cole et al (OTA Meeting; October 2004)

Fracture patterns dictate fixation strategy

Simple patterns
•

Absolute stability
Direct reductions

Need optimal soft tissue

Comminuted patterns
•

Relative stability
Indirect reduction

Soft-tissue preservation
 Respect distal tibial fractures
Complications
•

Wound breakdown
Infection

Malunion

Nonunion

Arthritis

Joint Stiffness

Amputation
Avoid complications!

•Soft tissues
Patience: Wait!
Meticulous handling

Careful closure

•Bone
Anatomic reconstruction of joint surface
Restore alignment

Preserve blood supply

Treatment algorithm

•Stabilize the soft tissues

•Wait for soft tissues to recover

•Understand the injury

 Create a surgical tactic

•Reconstruct articular surface and secure to
metadiaphysis
•Use implants that neutralize the deforming

forces and fixation strategies optimal for

fracture patterns
Take-home messages

•Axial loading injuries are a distinct high-energy

fracture type

•High-energy distal tibial fractures have severe soft-

tissue injuries

Staged protocols can reduce complications

•

Fracture patterns dictate fixation strategy

•