Management of Pilon Fractures—Current Concepts

Abstract

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

A Current Concepts Update in Pilon Fracture Management

“…Topliss in 2005 introduced a more advanced classification system using an axial CT scan to identify the six typical fragments: An anterolateral, anterior, posterior, posterolateral, medial, and central die-punch fragment (Figure 8). They are present with varying frequency and need to be analyzed carefully to choose the appropriate approach and plate position [25].…”

“…Most patients will most likely be able to undergo external fixation. Definitive use of external fixation, without articular reduction or fixation, has been used in highly comminuted or open pilon fractures to maintain length, alignment, and rotation [25]. The treatment chosen is heavily influenced by the surrounding soft-tissue environment.…”

“…Wound complications can result in deep infection, which can have disastrous effects. Delaying surgery for 5-14 days, once post-traumatic edema has reduced, may reduce the risk of wound problems [25].…”

“…Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction [25]. Stiffness and post-traumatic arthrosis pain occur due to the narrowing of the joint space after open reduction therapy and internal fixation.…”

“…Figure 8: An axial computed tomography of the distal tibia showing the typical six fracture fragments. A, anterior fragment; AL, anterolateral fragment; P, posterior fragment; PL, posterolateral fragment; C, central die-punch fragment; M, medial fragment; and F, fibula[25] …”