CASE 48 pilon fractures

A 29-year-old woman arrives to the emergency department after jumping from the second story of a burning building. Upon presentation, she is obtunded and

hemodynamically unstable. Her condition, however, stabilizes after transfusion of two units of packed red blood cells and two units of fresh, frozen plasma. She is found to have a subdural hematoma and a splenic laceration, which compels transfer to the intensive care unit for observation. On secondary survey, significant ecchymosis, swelling, and evolving fracture blisters are noted of the right ankle. The right foot has dopplerable signals over both the posterior tibial and dorsalis pedis arteries. An AP radiograph of the right ankle is shown in Figure 6–51.

 

 

Figure 6–51

The Volkman fragment typically observed in this injury retains connections to which of the following ligaments?

1. Anterior tibiofibular ligament

2. Posterior tibiofibular ligament

3. Interosseous membrane

4. Deltoid ligament

 

Discussion

The correct answer is (B). The Volkman (posterolateral) fragment retains its connections via the posterior tibiofibular ligament. The Chaput (anterolateral) fragment retains its connections via the anterior tibiofibular ligament.

The most appropriate initial management of this injury is:

1. Closed reduction and splinting

2. Application of ankle-spanning external fixator

3. Definitive open reduction and internal fixation within 72 hours of injury

4. Primary below-knee amputation

 

Discussion

The correct answer is (B). Attempts at early definitive fixation involving surgical approaches through a damaged soft tissue envelope have been fraught with complications including wound-healing problems and infection. As a consequence, staged protocols have been developed to address these injuries. Following closed, provisional reduction, application of temporary, ankle-spanning external fixation allows for provisional fixation and reestablishment of relative length and alignment. Definitive internal fixation of the tibia is approached once soft tissue swelling dissipates, which is commonly 7 to 14 days post-injury. Primary amputation in the setting of a well-perfused foot without gross significant soft tissue loss would be inappropriate.

According to the elements of successful pilon fracture management set forth by Ruëdi and Allgöwer, which of the following accurately describes the correct order of steps for fixation:

1. Restoration of fibular length, reconstruction of metaphyseal shell, metaphyseal–diaphyseal fixation, bone grafting

2. Reconstruction of metaphyseal shell, bone grafting, metaphyseal–diaphyseal fixation, restoration of fibular length

3. Restoration of metaphyseal shell, bone grafting, restoration of fibular length, metaphyseal–diaphyseal fixation

4. Restoration of fibular length, reconstruction of metaphyseal shell, bone grafting, metaphyseal–diaphyseal fixation

Discussion

The correct answer is (D). Ruëdi and Allgöwer’s classic description of the operative approach to pilon fracture fixation advocated a sequential approach: restoration of fibular length, reconstruction of the metaphyseal shell, bone grafting, and metaphyseal–diaphyseal fixation.

All of the following factors have been shown to negatively impact outcomes of patients with pilon fractures treated operatively EXCEPT:

1. Lack of a college degree

2. Marital status

3. Workman’s compensation

4. Annual income less than $25,000

 

Discussion

The correct answer is (C). Pollak et al. performed a retrospective analysis of 103 patients that underwent operative treatment of pilon fractures. Factors significantly related to poor results included: the presence of two or more comorbidities, being married, having an annual income less than $25,000, not having a high-school diploma, and having been treated with external fixation with or without limited internal fixation. Whether or not workman’s compensation was involved was not shown to be a significant predictor of poor outcomes.

 

Objectives: Did you learn...?

 

 

The staged management of pilon fractures? The anatomy associated with pilon fractures?

 

The patient-specific factors shown to predict outcomes pertaining to pilon fractures?