Mechanisms of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Pathoanatomy and Applied Anatomy
Management of Expected Adverse Outcomes and Unexpected Complications
Author’s Preferred Treatment
Stage 1: Fibular Open Reduction and Internal Fixation and Tibiotalar External Fixation
Stage 2: Definitive Tibial Open Reduction and Internal Fixation
Summary, Controversies, and Future Directions
From Marsh JL, Saltzman CL. Ankle fractures. In: Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood and Green Fractures in Adults. 6th ed. Philadelphia, PA. Lippincott Williams & Wilkins; 2006.
The author prefers to treat the vast majority of tibial pilon fractures with staged ORIF using the general principles outlined by Ruedi and Allgower four decades ago. Conceptually, however, pure isolated medial buttress plating, as originally described by Ruedi and Allgower, is far less important as choosing an implant, or implants, that are appropriate to support the anticipated loads that the articular and metadiaphyseal fracture components may encounter. Occasionally acute ORIF is performed, but only when the injury is of low energy, presents with little soft tissue swelling, and the injury pattern and surgical tactic can be discerned with plain radiographs and a comprehensible distal tibial CT scan. Treatment with definitive external fixation with or without small incision articular reduction and fixation is rarely utilized but when used, is typically reserved for those situations with severe associated soft tissue compromise, and/or patients and/or limbs that cannot tolerate open methods.
Each step of the treatment process is important and can have a substantial impact on the final operative result.
The initial evaluation of the fibula assesses:
The mechanism of fibular fracture often dictates not only the fibular fixation construct but may also suggest the direction from which the tibia should be primarily buttressed. Valgus, compression-failure fibula fractures often suggest that subsequent distal tibial metadiaphysis may be best supported with a laterally based tibial plate, whereas a tension-failure fibula frequently suggest that a medial tibial buttress plate may be preferred. The degree of comminution can help determine whether a periarticular fibular plate is best or whether simpler tubular-type implants can be utilized. As noted earlier, simple transverse fractures in the distal third of the fibula shaft can also be successfully managed with medullary fixation and avoid significant soft tissue dissection. For the reasons stated earlier, the author strives for anatomic fibular length, alignment, and rotation.
The initial evaluation of the tibia assesses:
The importance of assessing the Volkmann fragment is that it may be best managed concomitantly and acutely with ORIF of the fibula fracture thereby substantially increasing the ease of the subsequent definitive treatment stage. Similarly, long spiral metadiaphyseal extensions or large oblique fragments that present a substantial amount of articular surface at their distal portion are considered for acute ORIF as their acute reduction can provide several benefits including:
Acute partial tibial reduction and fixation is typically with short length small or mini-fragment plates and/or independent screws, and must avoid inadvertent fixation of other unreduced fracture fragments. This treatment strategy should be performed only when all of the definitive fixation construct has been thought through so as to not jeopardize the final choice of surgical approaches, implant placement, and soft tissue injury. If the operative plan cannot be completely delineated at the outset, either because of lack of or inadequate understanding of the CT scan, or the soft tissue envelope is not appropriate for acute interventions, then the author prefers to apply a simple external fixator, achieve as accurate reduction as possible, and repeat or perform imaging as needed. In the author’s opinion, it is far better to provide the best surgical tactic, reduction, and fixation in three or more stages than proceeding with a poorly planned and subsequently executed surgical plan in two stages.
After accurate fibular fixation, the author currently prefers to apply a biplanar tibiotalar spanning external fixator. A transcalcaneal pin is used, in addition to two tibial and a single cuneiform pin. The biplanar external fixator is subsequently used as the distraction device for the definitive tibial reduction and fixation stage, and therefore requires accurate placement of the talus beneath the anatomic axis of the tibia in the frontal plane, slight posterior translation in the sagittal plane, and satisfactory tibiotalar distraction in the horizontal plane. After fibular fixation and tibiotalar external fixation, a CT scan is obtained.
Definitive tibial reduction and fixation occurs after resolution of soft tissue edema, when wrinkles are present, and blisters have epithelialized. The axial, sagittal, and coronal CT scan images are very carefully reviewed to understand the articular injury. Important features are the location of comminution, impaction, and how the articular fragments relate to the metadiaphysis. On the CT scan, a clear understanding of the position, size, and relationship of the Volkmann fragment to the fibula, the tibia, and the rest of the articular surface is one of the initial assessments. This determines the best surgical approach, typically a choice between an anterolateral exposure or an anteromedial exposure. Valgus or abduction injuries with anterolateral plafond comminution and/or impaction without medial articular plafond comminution are ideal patterns for the anterolateral exposure. Increasing medial plafond comminution, and varus or adduction injuries are indications for an anteromedial exposure. Supplemental posteromedial or medial malleolar-type exposures can also be safely performed in conjunction with the anterolateral approach to manage coexisting medial malleolar or medial metaphyseal fractures, and are powerful adjunctive exposures. The anterolateral and anteromedial incisions are made to allow satisfactory visualization of the articular surface and the metaepiphyseal fracture lines, and retrograde plate insertion with proximal plate fixation often occurring percutaneously. Reduction of the articular surface utilizes all techniques, including anatomic reduction of any available cortical interdigitations, direct visualization of the articular surface, and fluoroscopic confirmation. A common sequence is accurate reduction of the posterolateral Volkmann fragment relative to the fibula, followed by correction of any dorsiflexion impaction of the articular surface. The Volkmann fragment is then reduced to the medial malleolar fragment along the posteromedial fracture line. Central plafond comminution is reduced and bone graft (if needed) is applied. The anterolateral Chaput fragment is subsequently reduced. Liberal use of K-wires of small diameter and occasional mini-fragment screw/plate devices are used to provide provisional fixation. The external fixator is useful for providing distraction and allowing visualization of the articular surface as it can maintain the talus in a slightly posterior, distracted, and plantarflexed position. After reduction and provisional fixation of the articular surface, the modularity of the external fixator allows it to indirectly reduce axial metadiaphyseal alignment if needed. Specifically, the distraction can be lessened and the metadiaphyseal fracture more accurately reduced and provisionally held with the external fixator. The choice of implant depends on the job that it is required to do. Coronal plane articular fracture lines are best secured with anterior–posterior fixation, whereas sagittal plane articular fracture lines are best secured from medial to lateral. Valgus injuries often require stiffer lateral buttress implants and the reverse is required for varus or adduction injuries. In those with significant metadiaphyseal injury, stiff lateral (typically anterolateral, but occasionally posterolateral) and medial implants are required. As noted, morselized allograft bone graft is occasionally required to fill epiphyseal bone voids to support articular surface fragmentation. Radiographic representation of the reduction and fixation sequence is provided in Figure 58-25.
The wounds are closed in layers with a monofilament absorbable suture for the deep layers and nylon modified Allgower–Donati suture for the skin. Patients are typically placed into a below knee splint with the foot in a neutral plantigrade position. Postoperative pain control is facilitated by a sciatic and femoral nerve block performed at the conclusion of the surgical procedure. The postoperative care plan previously outlined is utilized.