Not So Fast, Think Slowly: Which Ones I Plate Mani Kahn MD Images - - PowerPoint PPT Presentation

Not So Fast, Think Slowly: Which Ones I Plate

Mani Kahn MD

Images and Cases Heavily Borrowed from OTA Archive

No Disclosures

Mechanism of Injury

• High energy pilon fractures

– Significant axial force with translational/shear/rotational forces. – Rapid rate of force application – Articular and/or metaphyseal comminution. – Large amount of energy released – Significant soft tissue injury

Pilon Fixation

• Fixation options are determined by fracture

pattern, patient factors, and condition of soft tissue.

– Plate – Intramedullary nail – Thin wire/hybrid external fixator – Primary fusion

Determining a Treatment Strategy

≠

Not So Fast

Immediate ORIF….

• Frequent wound healing issues, deep infection

rates up to 55%

Kellam 1992

Think Slowly…

• Patient Factors
• Soft Tissues
• Staged Treatment
• Articular Assessment
• Metaphyseal Assessment

Patient Factors

• The best predictors of clinical outcomes were

patient demographic factors—socioeconomic status, sex, level of education, and workers’ compensation status

• Marsh et al 2003
• Diabetes
• PVD

Soft Tissue Assessment

• 1. Assess NV Status
• 2. Determine Compartment

Syndrome Risk

• 3. Assess

swelling/blistering/skin tenting

Define the Injury- Fracture Pattern

Varus

Understand Fracture Energy, Bone Quality, Primary Displacement

Axial Load Valgus

Staged Treatment

• External fixation +/- ORIF fibula for high energy pilon fxs
• Allow recovery of soft tissue injury
• Delayed ORIF of plafond injury

Define Articular injury after Distraction

Goal:

• 1. Define Reduction &

Fixation Strategy Mandate:

• 1. Anatomic

Reduction

• 2. Absolute Stability

Articular Assessment

• Anterior
• Posterior
• Medial
• Anterolateral
• Posterolateral
• Die-punch

Articular Assessment

Coronal

• Older patients
• Low energy injuries
• Valgus

Sagittal

• Younger Patients
• High energy
• Varus

Define Metaphyseal Fracture Pattern

ComplexRelative Stability SimpleAbsolute Stability

Define Metaphyseal Fracture Pattern

Goal:

• 1. Plan Reduction

Strategy(direct vs indirect) ?

• 2. Neutralization vs.

Bridge plate for metaphyseal fracture component

ComplexRelative Stability SimpleAbsolute Stability

Begging for a plate….

• Anatomic articular reconstruction
• Plate resistance of initial fracture displacement

vector

– Varus deformity medial buttress – Valgus deformity lateral buttress – Anterior/posterior talar escape anterior/posterior buttress

Define Mechanics of Instability

Goal:

• 1. Understand Forces You Must Resist

Precontoured Locking Plates

• Osteoporotic bone
• Extensive metaphyseal comminution
• Small articular fragments

Precontoured Locking Plates

• Posterior,
• Anterolateral
• Medial
• Simplify treatment in complex pilon fractures

by use of single approaches

34 yo female s/p MVC with closed 43C fx

34 yo female s/p MVC with closed 43C fx

• c

Minimally Invasive Plating

• Use of small incisions to restore mechanical

axes

• Decrease iatrogenic tissue injury
• Preserve fracture hematoma
• Lower SF-36 & excellent AOFAS scores in 83%
• f patients in high energy Pilon fractures with

long term followup

Special Circumstances: Open Pilon with Bone Loss

• Gardner et al reported on 10 pts with 43 C open pilons with segmental bone

loss treated with a standard protocol

– I&D and external fixation – Delayed definitive ORIF, antibiotic beads in bone defect. – Staged bone grafting at ~ 12 wks. If normal infxn labs.

Gardner et. al JOT 2008

References

• Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone

Joint Surg Am 2003;85(2):287-295.

• Kellam & Waddell J Trauma, 1979, Dillin et al J Trauma 1986, Ovadia et al JBJS Am 1986, McFerran et al JOT

1992, Teeny and Wiss CORR 1993

• Borrelli J Jr, Ellis E: Pilon fractures: Assessment and treatment. Orthop Clin North Am 2002;33(1):231-245,

x.

• Anglen JO: Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma

1999;13(2):92-

• 97.
• Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr: A staged protocol for soft tissue management in the

treatment of complex pilon fractures. J Orthop Trauma 1999;13(2):78-84.

• Patterson MJ, Cole JD: Two-staged delayed open reduction and internal fixation of severe pilon fractures. J

Ortho Trauma 1999;13(2):85-91.

• Tornetta P III, Gorup J: Axial computed tomography of pilon fractures. Clin Orthop Relat Res

1996;(323):273-276.

• Topliss CJ, Jackson M, Atkins RM: Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br

2005;87(5):

• 692-697.
• Mast J, Jakob R, Ganz R: Planning and Reduction Technique in Fracture Surgery. New York, NY, Springer-

Verlag, 1989.

• Rüedi T, Allgöwer M: Fractures of the lower end of the tibia into the ankle joint. Injury 1969;1:92-99.
• Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A