1. Distal tibial fractures
Author: Mark Lee
Reviewer: Mark Lee
Revised: 2018
AO Trauma Basic Principles Course

2. Learning objectives
Describe the anatomical characteristics of the distal tibia and why injuries of the distal tibia are unique
Define fractures requiring absolute stability and those amenable to relative stability, focusing on different fracture patterns
Recall techniques of internal fixation that avoid soft-tissue damage while preserving blood supply to the bone
Describe the role of the fibula in the operative treatment of distal tibial fractures
Teaching points:
Indirect reduction for preliminary stabilization and correction of length and alignment should be part of this lecture. Do not go into details of fixation techniques(!) utilizing joint-spanning distraction

4. Objectives By the end of this talk you should be able to:
Appreciate the significance of this injury
Understand the fracture characteristics
Describe the treatment principles
Avoid the potential complications

5. Description
“Pilon” (noun, French): pestle, an instrument used for crushing/pounding
Results from axial load
This is not just a torsional injury

6. Ankle versus pilon fractures
Low energy
Minor articular damage
Minimal swelling
High energy
Major articular damage
Significant swelling

7. Respect the pilon Complications: Wound breakdown Infection Malunion
Nonunion
Arthritis
Stiffness
Amputation

8. Problem: soft-tissue injury!

9. Evaluation History: Physical examination: Plain x-rays:
Associated injuries
Physical examination:
Focus on soft-tissue envelope
Careful neurological examination
Plain x-rays:
Ankle
Tibia
Computed tomographic (CT) scan after reduction and spanning if possible
Sacral U-shaped fracture
Spinopelvic dissociation

10. Fracture classification
AO/OTA Fracture and Dislocation Classification: 43
A: Extraarticular
B: Partial articular
C: Complete articular A1 A2 A3 B1 B2 B3 C1 C2 C3

11. Goals of treatment Anatomical articular reduction
Restoration of length, alignment, and rotation
Reattachment of joint to metadiaphysis
Sufficient stability to allow for early joint motion

12. Surgical indications Articular incongruity Joint instability
Limb malalignment

13. History
Open reduction and internal fixation (ORIF) yields excellent results
Rüedi et al (Injury. 1969;2:92–99)
ORIF has high complication rates
Kellam et al (J Trauma. 1979;19:593–601)
Rüedi TP, Allgöwer M. Fractures of the lower end of the tibia into the ankle-joint. Injury. 1969;1(2):92–99.
Kellam JF, Waddell JP. Fractures of the distal tibial metaphysis with intra-articular extension--the distal tibial explosion fracture. J Trauma Aug;19(8):593–601.
Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma Feb;13(2):78–84.
Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma Feb;13(2):85–91.
Staged ORIF minimizes complications
Patterson et al (J Orthop Trauma. 1999;13:85–91)

14. Open and closed fractures
Staged protocols
Sirkin, 1999
56 pilon fractures
Immediate fibular ORIF with ankle-spanning external fixation
Average 12.7–14 days to ORIF
1.8% wound dehiscence
3.6% infection
Patterson, 1999
22 pilon fractures type C3
Average 24 days to ORIF
73% Anatomical reductions
No infections
Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma Feb;13(2):78–84.
Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma Feb;13(2):85–91.
Open and closed fractures

15. Sirkin et al (J Orthop Trauma. 1999;13:78–84)
Staged protocol
1. Temporary limb stabilization 2. Await resolution of soft-tissue swelling 3. Study the injury 4. Staged reconstruction
Reference:
Sirkin M, Sanders R, DiPasquale T, et al. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma Feb;13(2):78–84.
Sirkin et al (J Orthop Trauma. 1999;13:78–84)

16. 1. Temporary limb stabilization
Restore lateral column length/stability:
Fibular reduction
Posterolateral incision
Creates a pillar
Fibular reduction can be difficult!
Reference:
Williams et al, JOT. 1998
Williams et al (JOT. 1998)

17. 1. Temporary limb stabilization
Restore medial column length/stability:
Spanning ankle external fixation
Anticipate future surgical approach
Anticipate implant position

18. 1. Temporary limb stabilization
Restore medial column length/stability
Spanning ankle external fixation
Anticipate future surgical approach
Anticipate implant position

19. 1. Temporary limb stabilization—frame application
Medial
Delta
Include foot when possible.
Include fourth pin to stabilize rotation/toggle around pin.

20. 1. Temporary limb stabilization—distract!
Use radiographic markers to judge length restoration:
Talar Chaput fragment
Talofibular relationships
Joint distraction
Talus beneath plafond, tibial shaft

21. 2. Wait on soft-tissue swelling
Wait some more
And some more
Wrinkles, skin pliability.

22. 2. Wait on soft-tissue swelling—timing priority: soft tissues
Stop
Caution
Proceed!

23. 2. Wait on soft-tissue swelling—surgical timing
Correct timing is critical
Patience!
Rarely day 1–6
Often day 14–21
Wrinkles

24. 2. Wait on soft-tissue swelling—While you are waiting...
Get additional information
Think!
Prepare a preoperative plan

25. 3. Study the injury Carefully study using: CT scan:
Axial, sagittal, coronal reconstructions
Understand injury
Develop surgical tactic
Tornetta and Gorup, CORR, 1993

26. 3. Study the injury—pilon map: axial CT scan
Experience:
Patterns emerge
Fragment recognition
Chaput, Medial, Volkmann
Zones of impaction
Anterior
Medial
Lateral
Posterior
And then reconstruct onto those columns: Chaput (anterolateral), Volkmann (posterolateral).
Cole PA, Mehrle RK, Bhandari M. The Pilon Map: Assessment of Fracture Lines and Comminution Zones in AO C3 Type Pilon Fractures. Poster presented at: OTA Annual Meeting 2004; October 8–10, Hollywood, FL, USA. Available at: Accessed January 24, 2014.
Cole PA, Mehrle RK, Bhandari M, et al. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma Jul;27(7):e152–156.
Cole et al (OTA Meeting; October 2004; Hollywood, FL)

27. 3. Study the injury— fracture patterns dictate fixation strategy
Simple patterns:
Absolute stability
Direct reductions
Need optimal soft tissue
Comminuted patterns:
Relative stability
Indirect reduction
Soft-tissue preservation

34. 3. Study the injury—respect distal tibial fractures
Complications:
Wound breakdown
Infection
Malunion
Nonunion
Arthritis
Joint stiffness
Amputation

35. 3. Study the injury—avoid complications!
Soft tissues:
Patience: wait
Meticulous handling
Careful closure
Bone:
Anatomical reconstruction of joint surface
Restore alignment
Preserve blood supply

36. 3. Study the injury—treatment algorithm
Stabilize the soft tissues
Wait for soft tissues to recover
Understand the injury:
Create a surgical tactic
Reconstruct articular surface and secure to metadiaphysis
Use implants that neutralize the deforming forces and fixation strategies optimal for fracture patterns

37. Take-home messages
Axial loading injuries are a distinct high-energy fracture type
High-energy distal tibial fractures have severe soft-tissue injuries
Staged protocols can reduce complications
Fracture patterns dictate fixation strategy