- See:
-
soft tissue reconstruction of the leg
-
fracture blister management
- Discussion:
- based on the injury to the soft tissue and whether the injury resulted from high or low injury trauma;
-
type I & II frx
- closed reduction, cast or splint application, and elevation;
- immediate ORIF can be considered if there is not excessive swelling or excessive soft tissue disruption;
-
type III B and C frx
-
operative timing and strategy:
- goal is to keep talus centered under the tibia and fracture out to length while soft tissue heal over 7 to 21 days;
- early medial incisions in the face of tense soft tissue swelling, risks wound infection and slough;
- the greatest risks seems to occur from ORIF of the medial column within 5 days of injury;
- in the study by
M. Sirkin MD et al 1999, a series of pilon fractures underwent immediate external fixation and ORIF of
the fibula, and formal ORIF of the tibial articular surface was performed on a delayed basis (avg delay 12-13 days);
- using this protocol, no patient that presented with a closed injury developed a full thickness skin necrosis and none required secondary
soft tissue coverage;
- the authors feel that the historically high rate of infection and skin necrosis following ORIF of these injuries is most related to operative timing;
- in the study by
MJ Patterson and JD Cole (JTO 1999), all patients underwent a two staged technique for the
treatment of complex pilon frx;
- initially all patients underwent immediate fibular fixation and placement of a medial fixator;
- in the report by
M. Blauth et al., the authors sought to determine whether long-term results of one of three different management protocols for severe tibial
pilon fractures offer advantages over the other two;
- authors recommend a 2-step procedure for the treatment of severe tibial pilon fractures with extensive soft tissue damage;
- first stage:
- includes primary reduction and internal fixation of the articular surface is performed using stab incisions, screws, and K-wires;
- temporary external fixation is applied across the ankle joint;
- second stage:
- requires recovery of the soft tissues;
- involves internal fixation with a medial plate using a reduced invasive technique;
-
calcaneal pin:
- calcaneal pin w/ 15-20 pounds of traction with the leg elevated on a Bohler frame allows
alignment of frx fragments and brings frx out to length while soft tissues are monitored;
-
external fixation:
- external fixation may substitute for calcaneal pin traction, and allows the frx to be brought out to length;
- may consist of a simple tibial fixator that
includes the foot, or may consist of a more elaborate
circular wire fixator;
- it is controversial whether or not to fix the fibula in these fractures, and it is further controversial as to whether to perform ORIF with the
initial fixator placement or to perform it on a delayed basis;
- note it is important to apply the fixator as medially as possible inorder to avoid the standard medial incision site (should it be necessary for articular restoration);
- ref:
External fixation of severely comminuted and open tibial pilon fractures.
-
case example: 40 year old female w/ grade 3b open pilon frx (seen on left), who was treated w/ a hybrid fixator which brought the frx out to length);
A staged protocol for soft tissue management in the treatment of complex pilon fractures. M. Sirkin et al. JOT Vol 13. No 2. 1999. p 78-84.
Surgical Options for the Treatment of Severe Tibial Pilon Fractures: A Study of Three Techniques
Open reduction and internal fixation of tibial pilon fractures.
The management of the soft tissues in pilon fractures.
A staged protocol for soft tissue management in the treatment of complex pilon fractures.
