Central articular (implosion) injury is the result of an axial load on the foot in neutral position. Topliss et al (2005) re-examined the anatomy of pilon fractures based on plain radiography and CT. The distal tibia is designated as #43 (4 = tibia, 3 = distal segment). Background Distal tibia fracture with intra-articular extension . METHODS: One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. The superficial peroneal and saphenous nerves are superficial to the fascia. Classification systems have been developed to stratify both severity of fracture pattern and soft tissue injury. Comminution, which frequently occurs with high-energy pilon fractures, is most typically located in the anterolateral and central regions of the plafond. The AO Spine Classification Group reached a consensus on a classification that incorporates both fracture morphology and clinical factors relevant for clinical decision making. Initial management of pilon fractures depends as much on the soft tissue as the bony injury. The articular surface of the distal tibia is concave in both the coronal as well as the sagittal plane. Complications after treatment of tibial pilon fractures: prevention and management strategies. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Tuesday, December 15, 2020: Pilon Fractures. 20-25% are open . Gustilo type 1 open fractures are generally clean with a < 1-cm skin laceration. The AO group has developed a comprehensive classification of fractures. Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for … The Tscherne scheme has 4 grades of increasing severity for soft tissue injury in closed fractures. They run together in the pericapsular fat between the extensory digitorum and extensor hallucis longus tendons. What is the most appropriate Gustilo-Anderson classification of this injury? These classifications are less reproducible and do not provide necessary information for proper surgical planning. The authors describe how this influences surgical approach but the data do not clarify this and the classification may need some further development to make a distinct contribution to decision making. Abstract Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. Login. Day 0. Luk (2013) compared pilon fracture types in patients with and without an intact fibula. The tendons of the anterior compartment, the dorsalis pedis artery, and the superficial and deep peroneal nerves can be encountered with anterior exposures at the level of the ankle joint. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. A pilon fracture is a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint. A severely traumatized soft tissue envelope accompanies the higher energy pilon fractures. Type 3 injuries portend the worst prognosis as a consequence of articular comminution and metaphyseal impaction. Type 3B are usually contaminated with extensive periosteal stripping and bone exposure necessitating flap coverage. The most common fracture pattern occurs with the ankle in dorsiflexion (i.e., the foot on the brake pedal during a motor vehicle accident). There are subtypes of each classification based on increasing complexity of the articular and metaphyseal components ( Fig. Dear Visitor, Your browser is currently not set to accept cookies. 4. AO/OTA Fracture and Dislocation Classification Long-bone Fractures 41B Partial articular 41B1 Split 41B2 Depression 41B3 Split depression 41C Complete articular 41C1 Simple articular, simple metaphyseal 41C2 Simple articular, wedge, or multifragmentary metaphyseal 41C3 Fragmentary or multifragmentary metaphyseal 43A Extraarticular 43A1 Simple A new CT-based classification from Bristol builds on the work of Tournetta and offers important new insights. Some surgeons have found that immediate (within a few hours of injury) open reduction, prior to significant swelling, can be performed safely. External fixation alone became popular for managing complex pilon fractures associated with both closed and open compromised soft tissue envelopes. Dr Daniel J Bell ◉ and Dr Yuranga Weerakkody ◉ et al. Axial CT shows fracture lines dividing the plafond into 3 major fragments: Anterolateral, posterior, and medial. Sclerosis is due to impacted bone fragments/trabeculae. Tibialis posterior tendonopathy/adult acquired flatfoot, 43A: extra-articular – most would not recognise these as pilon fractures, although in some series non-articular fractures are included and it can be difficult to tell how many were articular, 43B: partial articular fractures with some connection between part of the joint surface and the diaphysis - again, some series appear to include these but most do not clearly differentiate between them and those with complete separation between diaphysis and metaphysis. Fractures of the distal tibia have been given the number 43 in the AO Classification (Fig. The AO Spine classification of thoracolumbar injuries is one of the more commonly used thoracolumbar spinal fracture classification systems and aims to simplify and universalise the process of classifying spinal injuries and improve interobserver and intraobserver reliability 3.. Fortunately, pilon fractures compose a minority of tibia or lower extremity fractures, occurring in ~ 7% and 1% of all cases, respectively. 27(7):e152-6. The AO Spine Thoracolumbar and Subaxial Classification systems are the result of a systematic assessment and revision of the Magerl classification. To view this page please enable your cookie setting. The classical Chance fracture. There are also multiple small, comminuted fragments. In the most severe plafond fracture patterns, the articular segment is fractured into numerous pieces with certain segments driven proximally into the metaphysis, creating marked joint incongruity and associated metaphyseal defects. Understanding the soft tissue injury accompanying pilon fractures is of utmost importance for providing optimal treatment while minimizing complications. A pilon fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint.Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents. 2000 Jul-Aug. 8 (4):253-65. The classification system, broken into three categories focuses on the displacement and pattern of the fracture and the integrity of the coracoclavicular ligaments. Traction views may be valuable for further characterization of the pilon fracture. The AO long bone group universal classification of fractures groups distal tibia fractures as 43. The superficial peroneal nerve pierces the fascia of the lateral compartment ~ 12 cm proximal to the ankle joint en route to provide sensation to a majority of the dorsum of the foot. 2013 Jul. 43A: extra-articular – most would not recognise these as pilon fractures, although in some series non-articular fractures are included and it can be difficult to tell how many were articular 2. 3. The 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium for adults and children addresses the many suggestions to improve the application of the system, as well as add recently published and validated classifications. Limited ORIF to improve articular reductions without formal operative exposures was then employed to supplement external fixation strategies. Can be combined with subtypes of A or B. AO Spine Thoracolumbar Classification System Disclaimer: 1. . These can be challenging to manage, especially when associated with significant soft-tissue injury. Irreversible damage to the articular cartilage, and at times the soft tissues, occurs at the time of injury. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Core Knowledge in Orthopaedics: Foot and Ankle. METHODS: One senior attending, two fellows (one trauma, one foot and ankle), one junior orthopaedic resident, and one experienced research coordinator independently classified eighty-four sets of radiographs. J Orthop Trauma. Pilon fractures can occur from both low- and high-energy mechanisms. Surgical options include the following: Bridging external fixation, external fixation with limited internal fixation, nonspanning external fixation ± limited internal fixation, and staged open reduction and internal fixation. Appreciate the consistent Y pattern creating 3 main articular fragments. When the fibula was intact, 58% of fractures were partial articular type B. Retrieved Created Apr 04, 2012 02:40. 2013 Jul. What are the goals of treatment? With this type of injury, the other bone in the lower leg, the fibula, is frequently broken as well. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). The fractures are divided into types and further into groups then subgroups. J Orthop Trauma. Moderate interobserver reliability makes the AO/OTA system reliable for classifying pilon fractures (Swiontkowski et al 1997). The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. 1-10% of LE fx’s . Reports describing ORIF of tibial pilon fractures revealed a concerning complication rate with higher energy pilon fractures, including wound problems, deep infection, nonunion, and malunion (McFerran et al 1992, Teeny and Wiss 1993). OrthopaedicsOne Articles. Module. The systems used to classify the displaced distal pilon fractures are supposed to ensure the three-dimensional assessment of the fracture and provide high inter- and intra-observer agreement. Small wire epiphyseal-diaphyseal ring fixators were then employed to treat pilon fractures to allow for early ankle motion in an effort to minimize long-term ankle stiffness. 2000 Jul-Aug. 8 (4):253-65. 2013 Jul. Pilon fractures treated with a cast have led to poorer outcomes than those managed operatively. Learn more. Classification. The pilon fracture usually has an anterolateral (Chaput) fragment and a posterolateral (Volkmann) fragment, which usually remain attached to the distal fibula segment by the anterior and posterior tibiofibular ligaments. Type 2 open fractures have more extensive soft tissue injury with minimal to moderate crushing, typically with a laceration > 1 cm. J Am Acad Orthop Surg. The tendinous and neurovascular structures are covered proximally by the investing fascia of the anterior compartment and distally by the extensor retinaculum. A pilon fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint.Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents. . Two main classifications are used, which use different criteria for grouping. 27(7):e152-6. The first sub-grouping is on the degree of cntinuity between diaphysis and metaphysis: 1. The dorsalis pedis and deep peroneal nerve are at risk with an anterior exposure. A diagram summarising fracture alignments is provided, which implies very few fracture lines in intermediate positions between the coronal and sagittal families - it would be valuable to reproduce this in a different data set. Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. Classification. J Orthop Trauma. We help you diagnose your Distal tibia case and provide detailed descriptions of how to manage this and hundreds of other pathologies Pilon fractures with extensive crush, degloving, or vascular injury are considered type 3. Posterior partial fracture overlap with malleolar fractures with posterior malleolar components (Klammer 2013), and anterior partial fractures were included by Lauge-Hansen (1950) iin his classification of malleolar fractures, 43C: complete articular fractures with no connection between the joint surface and diaphysis – most pilon fractures fall into this group, 43C1: no comminution of epiphysis or metaphysis, 43C2: comminution of metaphysis but not epiphysis, 43C3: comminution of epiphysis +/- metaphysis (corresponding roughly to Ruedi-Allgower group III, many pilon fractures are in this category). A systemic motor and sensory examination is warranted in addition to documentation of distal pulses. 3. Anterolateral comminution is commonly encountered with high-energy fractures. Ruedi and Allgower revolutionized the management of pilon fractures after reporting their operative strategy in 1969. tension band. 2000 Jul-Aug. 8 (4):253-65. In view of the fact that most pilon fractures usually occur as the result of violent trauma (i.e., motor vehicle accident), associated bodily injuries must be considered in the work-up of these patients. This relatively rare injury (< 10% of lower extremity fractures) usually occurs in adults (aged 30s to 40s) owing to a fall from height or a motor vehicle crash [ 6 ]. At the level of the ankle, the distal tibia is intimately associated with the fibula through strong ligamentous attachments. AO/OTA Fracture and Dislocation Classification Compendium—2018. RESULTS: This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. Although many pilon fractures are open injuries, closed fractures have significant soft tissue compromise as well. The AO classification of clavicular fractures along with the Neer classification system is one of the more frequently used classification systems when assessing distal clavicular fractures.. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness (Babis et al 1997, Sands et al 1998, Pollak et al 2003). Explore AO Trauma's varied teaching and learning materials to enhance your expertise. joint-spanning articulated vs. nonspanning hybrid ring. The AO long bone group universal classification of fractures groups distal tibia fractures as 43 and divides this into: 43A: extra-articular – most would not recognise these as pilon fractures, although they appear in some series 43B: partial articular fractures with some connection between part of the joint surface and the diaphysis In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Fixator constructs spanned the ankle joint until fracture union, resulting in unacceptable ankle stiffness more... 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