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: pilon fracture
: 2006. 7. 22.
:
: 20113120
PK admission note
; O
; 358796
/ ; F / 36
admission date ;
1 :2006.5.20.
2 :2006.6.08
1. Chief complication
Right ankle pain (onset : 2006.05.20.)
2. Present illness
passenger TA C/C . ER
admission.
3. Past medical history
DM/HTN/TB/Hepatitis(-/-/-/-)
4. Physical examination
1) Vital sign ; stable
2) Rt ankle : External wound (+) : supf. abrasion 1cm
on calcaneous tuberosity 2cm area
Tenderness (+) & Swelling (+) : on whole ankle area
Ecchymosis (-)
Distal sensory, motor, contraction : intact
ROM - limitation due to pain
6. ECG
7. Impression
#1. pilon fx distal tibia Rt.
#2. fx lat. malleolus ankle Rt.
8. Plan
DP>#1. CT for fx site
#2. bone scan
TP>#1.consider temp External fixation
change to plate with screw
#2.antibiotics
#3.Rt. leg elevation
#4.sensory, motor, circulation check
Pre OP note
bullae(+)-> dressing with flazile gauze
ECG : normal sinus rhythm
Brief op note
(06. 05. 23)
under spinal anesthesia
pre-op diagnosis : pilon fx ankle Rt.
(Ruedi allogower class III)
post-op diagnosis : same as above
op name : CRIF monofixation
operator : prof.
assists : R4 , R3 ,int
postop H-vac was inserted
Progression note
POD #1. (2006.5.24)
hyposthesia(+) 1st web space
big toe dorsiflexion : grade 4
->splint release for peroneal n
POD # 7. (2006.5.30)
bone scan checked
: hot uptake Rt. distal tibio fibular area
wound : wet
bullae : dry
distal sensory : intact
motor : intact
circulation : intact
further evaluation .
PK admission note
2 :2006.6.08
1. Chief complication
for post OP care
2. Present illness
passenger TA ER admission.
06. 05.23 pilon fx ankle Rt imp temporary monofixation OP
further evaluation post op care .
3. Past medical history
DM/HTN/TB/Hepatitis(-/-/-/-)
4. Physical examination
1) Vital sign ; stable
2) Rt ankle : status post monofixation
7. Impression
#1. pilon fx ankle Rt. (Ruedi allogower class III) s/p monofixation
8. Plan
#1. pain control
#2. antibiotics
#3. keep splint
#4. consider ORIF
Progression note
HD #4. (2006.6.11)
wound : clear
bullae(+): wet
distal sensory, motor, circulation
: no interval change
bullae healing OP delay .
HD #7. (2006.6.14)
wound : clear
bullae(+): wet improved
distal sensory, motor, circulation
: no interval change
Brief op note
(06. 06. 17)
under spinal anesthesia
pre-op diagnosis : pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
post-op diagnosis : same as above
op name :1) ORIF with 1/3 tubulr plate(8 holes) for ankle
2) ORIF with DMT plate (7-holes)
allogenous B.G & K-wire * 2 & monofixation
operator : prof.
assists : R4 , R3 , intern
postop S-drain tube was inserted
postop compression dressing was done & Long Leg Splint applied
post op X-ray
06.07.08
imp: pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
->06.05.23 CREF with monofixation
06.06.19 ORIF with 1/3 tubulr plate(8 holes) for ankle
ORIF with DMT plate (7-holes)
allogenous B.G & K-wire * 2 & monofixation
Brief op note
(06. 07. 20)
under IV anesthesia
pre-op diagnosis : pilon fx ankle Rt. s/p monofixation
(Ruedi allogower class III)
post-op diagnosis : same as above
op name : External fixation removal
operator : prof.
assists : int.
post OP X-ray
Review of disease
1. :
1)Classification: (Ruedi-Allgower):
- type I: Pilon Frx
- malleolar frx w/ significant axial load at time of injury & therefore large posterior plafond fragments;
- type II: Pilon Frx
- spiral extension frx;
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- Discussion:
- articular fracture without significant displacement;
- malleolar fractures with large plafond fragments;
- these fragments are usually posterior;
- posteroinferior tibiofibular ligament & deep transverse ligament are attached to the fragment;
- first reduce & fix fibula;
- may usually be accomplished w/ lag screw & neutralization plate;
- because of the intact state of ligamentous connection to posterior fragment, reduction of fibula
usually restores length relationship of posterior plafond fragment;
- distal tibia is exposed;
- large posterior fragment needs to be identified;
- large pointed reduction forceps are placed from anterior to posterior, holding the large
fragment firmly reduced;
- fixation should include lag screw placed from posteromedial to posterolateral or posterior;
- medial malleolar fragment is reduced & fixed w/ lag screw or tension band;
Type II Pilon Frx
--------------------------------------------------------------------------------
- Discussion:
--------------------------------------------------------------------------------
- Discussion:
- severe articular comminution and articular impaction frx;
- reduce fibula then perform plate & lag screw fixation;
- restores length of fractured distal tibia:
- reduce articular surface
- carried out & maintained by temporarily stabilizing it with K wires;
- because of impaction of joint surface upward into metaphyseal cancellous bone, reconstruction
of the joint surface is assoc w/ producing a metaphyseal defect in the transitional bone
between joint & shaft;
- this must be filled in with a cancellous bone graft;
- buttress plate:
- addresses comminution in medial metaphyseal cortical bone,
- function of this plate is to provide support to this weakened area and prevents varus deformity;
~~~~~~~~~~~~~
Tibial Plafond Fracture
(w/ assistance and narration by Dr Kyle Dickson MD)
- Discussion:
- term pilon (hammer) fracture was introduced to describe these compression injuries by Destot in 1911;
- frx components:
- combination of ankle frx & distal tibial metaphyseal frx, usually w/ intra articular comminution;
- frx of medial malleolus;
- frx of anterior margin of tibia;
- transverse frx of posterior tibial surface;
- 20-25% of these will be open;
- mechanism of injury:
- vertical loading drives talus into distal tibia;
- position of foot & rate of loading affect injury pattern;
- it is important to distinguish between low energy frx (from skiing) vs high energy frx (as from MVA);
- plantar flexion: posterior articular damage;
- dorsiflexion: anterior articular damage;
- fibular frx:
- if fibula is frxed, then force involved is usually valgus shear w/ severe injury to the lateral aspect of the
joint;
- fibula intact: (25% of injuries);
- pilon frx w/o assoc frx of fibula occur in approx 15 % of cases;
- w/ compression injuries fibula may remain intact, which never happens w/ shearing type injury;
- w/ intact fibula, ankle is often driven into varus w/ severe impaction of the medial part of the tibial
plafond;
- associated injuries: (30% will have ipsilateral injuries and 5-10% will have bilateral injuries;)
- compartment syndrome
- compression frx of vertebral column, particularly L1;
- contralateral fractures of: os calcis, tibial plateau, pelvis, or acetabulum (verticle shear injuries):
- outomes:
- with operative treatment, high energy pilon fractures will take 4 months on average to heal;
- 75% of patients who do not develop wound complications may expect a good result;
- subsequent arthrodesis rate may be as high as 10%;
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- Exam:
- soft tissue: note presence of swelling and any fracture blisters;
- perform an Allen test using a pulse oximeter for the foot vasculature (pulse ox is placed on the toe);
- note function of posterior tibial pulse while the dorsalis pedis pulse is occluded and vice versa;
- ideally, the pulse ox should demonstrate normal mp3e forms even w/ occlusion of either vessel;
- reference: The management of the soft tissues in pilon fractures.
-------------------------------------------------------------------------------- Radiographs:
- consider taking a traction x-rays of extremity to help judge effects of ligamentotaxis on displaced
articular fragments;
- note whether fibula is intact or fractured;
- w/ comminuted fibular fracture it is important to bring fibula out to length (talo-crural angle)
- w/ fibula intact, carefully evalute the syndesmosis;
- type A:
- minimal or no anterior tibial cortical communition, two or more large tibial articular fragments, and
usually an
oblique or transverse fibular fracture at the level of the plafond (or ankle joint);
- type B:
- results from severe axial compression force, causing distal tibial bony impaction and comminution;
- CT scan: helps plan surgical fixation of articular fragments;
- ref: Treatment of displaced pylon fractures with circular external fixators of Ilizarov.
K. Aktuglu MD et al. Foot and Ankle International. Vol 19. No 4. Apr 1998. p 208.
- external fixation - foot inclusion;
- cancellous bone grafting of metaphyseal defect:
- wound closure:
***
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- Complications:
- wound complications and infection:
- w/ tranditional early ORIF of the tibial articular surface the occurrance of wound slough and infection
has ranged from 10 to 50%;
- some authors feel that this complication can be minimized by delayed ORIF (once the swelling has
diminished);
- 37% deep infection rate in tibial plafond Redi III (Teeny, Clin Orthop 1993);
- unplanned surgery for complications (Wyrsch, JBJS 1996)
- 55% for ORIF
- 18% for external fixation and limited ORIF
Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea
: pilon 2
.
: 10 17 (, 14-20) 1
. 8 (73%), 2 (18%), 1 (9%)
7 (64%), 3 (27%), 1 (9%).
: 2 pilon
.
Purpose: To evaluate the short-term results of two-staged delayed open reduction and internal fixation in
tibial pilon fractures with severe soft tissue damages.
Materials and Methods: Eleven patients, who underwent two-staged delayed open reduction and internal
fixation for tibial pilon fractures between January 2002 and July 2003, were followed for more than one
year. The mean interval time between first stage and second stage of the procedures was 28.5 days
(range, 14-34 days). Radiographs were graded by the criteria of Burwell and Charnley and ankle functions
were graded by the criteria of Mast and Teipner. Ankle function, union time and postoperative
complications were also analysed.
Results: Average union time was 17 weeks (range, 14-20 weeks) in ten of the eleven fractures, but there
was one fracture resulting in soft tissue complication and infected nonunion. At the lastest follow-up,
review of the radiographic results showed that eight fracture (73%) achieved an anatomic reduction, two
(18%) achieved a fair reduction, and one (9%) achieved a poor reduction. And clinical functional
assessment showed that there were seven (64%) good results, three (27%) fair results, and one (9%) poor
result.
Conclusion: Two-staged delayed open reduction and internal fixation technique is an excellent option for
the treatment of tibial pilon fractures with severe soft tissue injuries.
Treatment of Articular Fracture of the Distal Tibia (Pilon Fracture) with Limited Open Reduction and
External Fixator
( Journal of the Korean Society Fractures )
2000 13 2 p.272 ~ p.280
(Hui Taek Kim )
(Moon Bok Song )
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