Pilon Fractures Workup

  • Author: Vinod K Panchbhavi, MD, FRCS, FACS; Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: May 17, 2012
 

Laboratory Studies

  • If patients have preexisting conditions or comorbidities, then appropriate blood investigations are ordered.
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Imaging Studies

  • Plain radiographs, including anteroposterior, mortise, and lateral views centered over the ankle, help provide an understanding of the fracture fragments and the pattern.
  • In addition to these radiographs, obtain full-length radiographs of the leg, including the knee and ankle, to help assess alignment and to rule out any other fractures in the limb.
  • Plain radiographs of the contralateral ankle help provide a template for reconstruction of the ankle. Other areas of the body, such as the spine in the case of a fall from height, may require radiographic evaluation, depending on clinical findings.
  • The following 2 fracture classifications are commonly used; both are based on the fracture pattern seen on radiographs, the degree of comminution, and displacement of the fragments.[6, 7]
    • The Rüedi and Allgöwer classification is as follows:
      • Type A: These are simple cleavage-type fractures with little or no articular displacement (see images below).Low-energy fracture in the distal tibia with no siLow-energy fracture in the distal tibia with no significant displacement. Lateral view of pilon fracture. Lateral view of pilon fracture.
      • Type B: With these, displacement of the articular surface occurs without comminution (see images below).Low-impact pilon fracture with displacement but wiLow-impact pilon fracture with displacement but without significant comminution. Lateral view of pilon fracture. Lateral view of pilon fracture.
      • Type C: Intra-articular displacement occurs with marked comminution (see images below) (see images below).Significant comminution and displacement of fractuSignificant comminution and displacement of fracture fragments in a pilon fracture. Lateral view of pilon fracture. Lateral view of pilon fracture.
    • The AO/OTA classification (part of a comprehensive classification of long-bone fractures and tibia, numbered 43) is as follows:
      • Type A: These fractures are extra-articular and subcategorized as simple (A1), comminuted (A2), or severely comminuted (A3).
      • Type B: These fractures involve only a portion of the articular surface and a single column. Subcategories include pure split (B1), split with depression (B2), and depression with multiple fragments (B3).
      • Type C: These fractures involve the whole of the articular surface. Type C fractures may be categorized as a simple split in the articular surface and the metaphysis (C1), an articular split that is simple with a metaphysis split that is multifragmentary (C2), or a fracture with multiple fragments of the articular surface and the metaphysis (C3).
  • CT scanning of the distal tibia and ankle joint is almost mandatory, and it yields a better understanding of the fracture pattern, the comminution, the displacement, and the impaction of articular fragments. This can be valuable in planning the operation, such as to help determine the approach to the fragments and the orientation of the screws (see images below). CT scan showing an axial cut of the pilon fractureCT scan showing an axial cut of the pilon fracture. Minimally invasive plating technique performed as Minimally invasive plating technique performed as a second stage in the treatment of the pilon fracture.
  • Angiography is required if vascular compromise is suspected.
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Contributor Information and Disclosures
Author

Vinod K Panchbhavi, MD, FRCS, FACS  Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FRCS, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Royal College of Surgeons of England, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James K DeOrio, MD  Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Foot and Ankle Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Shepard R Hurwitz, MD  Executive Director, American Board of Orthopaedic Surgery

Shepard R Hurwitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American College of Rheumatology, American College of Sports Medicine, American College of Surgeons, American Diabetes Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Association for the Advancement of Automotive Medicine, Eastern Orthopaedic Association, Orthopaedic Research Society, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Stryker Consulting fee Consulting; Biocomposite Grant/research funds Other

References

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Low-energy fracture in the distal tibia with no significant displacement.
Lateral view of pilon fracture.
Low-impact pilon fracture with displacement but without significant comminution.
Lateral view of pilon fracture.
Significant comminution and displacement of fracture fragments in a pilon fracture.
Lateral view of pilon fracture.
Soft tissue trauma, with blister and area of pressure necrosis over the medial aspect of the distal leg, in a patient who presented 48 hours after the injury.
Significantly displaced medial malleolar fragment responsible for the area of pressure necrosis.
Lateral radiograph of pilon fracture.
Necrotic area is excised and a bead pouch covers the wound.
Wound on medial aspect of ankle after 8 days.
Split skin grafting of wound.
Pilon fracture stabilized by a minimally invasive technique.
Pilon fracture stabilized with cannulated screws.
Patient with full active plantar flexion at 2-year follow-up.
Picture at 2-year follow-up showing full active dorsiflexion.
Patient at 2-year follow-up.
Pilon fracture showing significant comminution and displacement.
Lateral radiograph of pilon fracture.
External fixator stabilizing the pilon fracture. Swelling has resolved, and blisters have healed.
External fixator maintaining improved alignment of the pilon fracture.
Alignment in lateral view of the pilon fracture, stabilized in an external fixator.
CT scan showing multiple fragments in the articular dome of the pilon fracture.
CT scan showing an axial cut of the pilon fracture.
Minimally invasive plating technique performed as a second stage in the treatment of the pilon fracture.
Lateral view after minimally invasive plating of the pilon fracture.
 
 
 
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