Early open reduction and internal fixation of Pilon fractures

Abstract

After some general considerations concerning the blood supply to the bone and skin, and the timing of the surgery, the different approaches to Pilon fractures are presented. These approaches have to be planned according to 3D CT reconstructions to provide the best visual control over the reduction manoeuvres without creating supplementary damage to the blood supply to the bone and skin. This article then reviews in detail the steps of reduction and internal fixation for different types of fractures. As a principle, it is recommended to begin with the fixation of the fibular fracture unless it is comminuted. In these cases a bridge plate osteosynthesis is made after tibial reconstruction.Tibial articular reconstruction can be achieved “from outside” in case of simple large fragments (AO types B1 and C1), or under direct visual control in case of comminution. There are different options for fixation, from isolated screws, eventually combined with intramedullary nailing in some simple fractures, to locking plates for complex fractures. There is no place anymore for conventional plating in pilon fractures. Pre-shaped locking plates are frequently used. In contrast, the AO LCP pilon plate can be placed at any position around the distal tibia depending on the fracture anatomy and the approaches. It has to be cut and adapted individually to each case. The extremities of the plate have to be glided below the soft tissues and screws inserted through stab incisions when necessary, to avoid additional soft tissue damage. In the postoperative care a plaster cast for 6 weeks is a reliable option to avoid equinus and secondary rehabilitation problems.In conclusion, open reduction and internal fixation of pilon fractures remains a challenge, but preoperative 3D CT reconstructions for planning, and fixation with locking plates changed dramatically the way of treating and the prognosis of these severe fractures.