April issue.indd

The early management of severe tibial pilon fractures using a temporary ring fixator

B.J. Mockford L. Ogonda D. Warnock R.J. Barr C. Andrews
Fracture Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA

Correspondence to: B.J. Mockford, 45 Waringfield Avenue, Moira, Craigavon, Co. Armagh, BT67 0FA, Northern Ireland

Keywords: Pilon fractures, tibial plafond, Ilizarov frame
Surg J R Coll Surg Edinb Irel., 1 April 2003, 104-107

Background: The management of pilon fractures of the distal tibia is fraught with complications. Poor initial management leads to a poorer outcome. Protection of the soft tissue envelope is paramount and to achieve this objective early fracture reduction, restoration of leg length and elevation are important principles in the management of severe injuries. Reduction and restoration of length can be achieved through ligamentotaxis by various methods but the most commonly employed are calcaneal traction or bridging external fixation. Objective: We describe our method for the early management of these injuries using a simple semicircular bridging frame

INTRODUCTION
Fractures involving a major part of the articular surface of the distal tibia are difficult to manage. The term ‘tibial pilon’ was first described by the French radiologist Destot in 1911 who likened the shape of the distal tibia to a pestle and compared the explosive impact of the talus against the tibia to that of a hammer striking a nail.¹ Pilon fractures are high-energy injuries and the primary component of force is vertically directed through the talus into the distal tibia. Characteristically, pilon fractures show varying degrees of impact of the supraarticular metaphysis, comminution of the tibial plafond and primary articular cartilage damage. There is usually associated major disruption of the soft tissue envelope directly proportional to the amount of energy involved in the traumatic event. Three principles exist in the emergent management of pilon fractures prior to any definitive surgery. Firstly, the fracture must be reduced and leg length restored. Secondly, the ankle should be stabilised and lastly, the leg elevated. Reduction and restoration of length can be achieved through ligamentotaxis by various methods but those most commonly employed are calcaneal traction or bridging external fixation. We describe a method that we have used for these injuries with a simple semicircular bridging frame.

Figure 1: Pre-operative AP and lateral radiographs of a compound Type III pilon fracture of the tibia

CASE 1
A 43-year-old male painter fell 12 feet from a ladder landing on his right leg. He had sustained an open Gustillo and Anderson Grade IIIb pilon fracture of his right tibia classified as a Reudi and Allgˆwer Type III fracture with significant soft tissue injury (Figure 1).² Four hours after his injury he proceeded to debridement of the 8cm medial wound and application of a temporary Ilizarov frame to restore leg length and to limit further soft tissue injury (Figure 2). Five days later he underwent definitive surgery. The course of his treatment was uncomplicated.

CASE 2
A 36-year-old male was admitted following a motorcycle accident with a closed Reudi and Allgöwer Type III fracture of his right tibia (Figure 3). There was significant pressure on the medial side of the ankle. Five hours after his injury he proceeded to the application of a temporary Ilizarov frame to restore leg length and to limit further soft tissue injury (Figure 4). Seven days later he proceeded to definitive surgery.

CASE 3
An 18-year-old male painter fell eight feet from a ladder landing on his right leg. He sustained a closed Reudi and Allgˆwer Type III tibial pilon fracture. His ankle was extremely swollen and leg shortened. Four hours after injury he had a temporary Ilizarov frame applied to restore leg length and to protect soft tissues. Post-operative viability of the skin was easily monitored as the frame allowed unrestricted access for soft tissue inspection and wound care (Figure 5). Six days later he proceeded to definitive surgery.

Figure 2: Post-operative radiographs after debridement and application of a temporary ring fixator (AP view above, lateral view below)

PROCEDURE
The patient is positioned supine on a fracture table and the leg is cleaned and draped. A frame is assembled using four half rings. The proximal end is a complete ring connected to two distal half rings by rods (Figure 6). An Ilizarov 2mm K-wire with an olive is inserted transversely through the calcaneum from the lateral side. Traction is applied through the calcaneal pin and frame length determined by the positioning of the second 2mm K-wire with an olive a suitable distance from the fracture site along the diaphysis of the tibia. Leg size and initial swelling determine the size of the rings to be used and allowance must be made for further soft tissue swelling. The frame is distracted between the wires under image intensifier control and tightened when a suitable reduction and correction of shortening has been achieved. Post-operative radiographs may be taken and further imaging such as a CT scan is usually required prior to definitive surgery.

DISCUSSION
The management of pilon fractures of the distal tibia is fraught with complications. Poor initial management leads to a poorer outcome. Protection of the soft tissue envelope is paramount. Swelling around the affected ankle is the predominant feature on presentation and in the first 8-12 hours is due to fracture haematoma and limb shortening. The majority of these fractures (75-85%) have an associated fibular fracture which along with metaphyseal comminution and surrounding muscle contraction always produces some degree of shortening.^3,4After 12 hours further swelling is due to intradermal oedema. There is an overall 29.4% incidence of fracture blister occurrence which markedly increases the risk of post-operative wound problems.^3,5 Maintenance of length allows improvement of vascular inflow and outflow decreasing oedema and allowing the soft tissues to heal. Soft tissue ischaemia is usually maximal within 24 hours of injury but a degree of ischaemia may develop up to the sixth day.⁶ Initial evaluation should include an examination for associated injuries, most commonly fractures of the calcaneum, tibial shaft, tibial plateau, proximal fibula, femur, pelvis, acetabulum, and lumbar spine.^6,7 Also, a careful examination of the soft tissues is carried out to identify an open injury and assess neurological status with a high index of suspicion for compartment syndrome.

Initial management should include immediate immobilisation of the limb, which is imperative to prevent further damage to the soft tissue envelope. Prior to definitive management three basic principles should be followed: firstly, fracture reduction and limb length restoration; secondly, ankle stabilisation and lastly, limb elevation.8 Ruëdi and Allgöwer Type I fractures may be placed into well-padded splints. More severe fractures, some Type II and all Type III injuries, require external traction to protect the soft tissues.^9,10 This can be achieved in the form of either, rigid external fixation or calcaneal traction.

External traction using a temporary construct like the Ilizarov frame provides a simple, stable and minimally invasive alternative in the early treatment of open or closed fractures of the tibial plafond. It is useful in soft tissue protection prior to definitive surgery. It also allows unrestricted access to the soft tissues for inspection, wound care and further imaging such as CT scanning; all vital components of preoperative planning for definitive surgery. This is now the method of choice in the early management of severe tibial pilon fractures in the Royal Victoria Hospital, Belfast.

Figure 3: Pre-operative AP and lateral radiographs of a Type III pilon fracture of the tibia (AP view above, lateral view below)

Figure 4: Post-operative radiographs after application of a temporary ring fixator

Figure 5: Post-operative picture of the ring fixator in-situ. The soft tissues are readily accessible for inspection and wound care (Medial view above, lateral view below)

REFERENCES
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