History and Physical Examination
Patients involved in high-energy trauma should be treated according to advanced trauma life support (ATLS) guidelines because they may have associated life- or limb-threatening injuries.
Obtain a history of any allergies, intake of medications, past medical history (eg, diabetes mellitus, peripheral vascular or neuropathic disease), and events leading to the injury. An understanding of the mechanism of injury may lead to an indication of the forces involved. Also, knowledge of any history of previous trauma in either limb is helpful during restoration.
Clinical presentation varies, depending on the severity of the injury and the duration from the time of the injury. Soft tissues swell rapidly, and tissue tension can produce enormous blisters. The underlying bony fragments may be significantly displaced, threatening the viability of the overlying soft-tissue envelope. Crushing, degloving, bruising, hematomas, and leaving the limb dependent can further compromise soft tissues (see the image below).
Soft-tissue trauma, with blister and area of pressure necrosis over medial aspect of distal leg, in patient who presented 48 hours after injury.
Classification
The Oestern and Tscherne classification of soft-tissue injury in closed fractures is as follows [19] :
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Grade 0 - Minimal soft-tissue damage, indirect injury to limb (torsion), simple fracture pattern
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Grade 1 - Superficial abrasion or contusion, mild fracture pattern
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Grade 2 - Deep abrasion with skin or muscle contusion, severe fracture pattern, direct trauma to limb
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Grade 3 - Extensive skin contusion or crush injury, severe damage to underlying muscle, subcutaneous avulsion, compartment syndrome
Traumatic wounds can range from a puncture wound, which is usually either medial or lateral, to large injuries with extensive loss of soft tissue.
The Oestern and Tscherne classification for open fractures uses wound size, level of contamination, and fracture pattern to grade open fractures, and is as follows [19] :
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Grade I - Open fractures with a small puncture wound without skin contusion, negligible bacterial contamination, and a low-energy fracture pattern
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Grade II - Open injuries with small skin and soft-tissue contusions, moderate contamination, and variable fracture patterns
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Grade III - Open fractures with heavy contamination, extensive soft-tissue damage, and, often, associated arterial or neural injuries
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Grade IV - Open fractures with incomplete or complete amputations
The Gustilo classification can also be used for open fractures and is as follows [20, 21] :
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Grade 1 - Skin lesion smaller than 1 cm; clean, simple bone fracture with minimal comminution
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Grade 2 - Skin lesion larger than 1 cm, no extensive soft-tissue damage, minimal crushing, moderate comminution and contamination
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Grade 3 - Extensive skin damage with muscle and neurovascular involvement, high-speed injury, comminution of the fracture, instability
Grade 3 Gustilo fractures may be further subclassified as follows [20] :
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Grade 3a - Extensive laceration of soft tissues with bone fragments covered, usually high-speed traumas with severe comminution or segmental fractures
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Grade 3b - Extensive lesion of soft tissues with periosteal stripping, contamination, and severe comminution due to high-speed traumas; usually requires replacement of exposed bone with a local or free flap as a cover
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Grade 3c - Exposed fracture with arterial damage that requires repair
Any neurovascular injury must be documented at the time of presentation. Compartment syndrome is a risk in acute injuries; therefore, frequent evaluations are necessary. A systematic and complete evaluation is necessary because other injuries (eg, to the spine or other extremities) may have occurred after a fall from height.
On the basis of the mechanism of injury and the degree of damage to soft tissue and bone, pilon fractures can be divided into two broad categories, low impact and high impact.
Low-impact pilon fractures have the following characteristics:
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Mechanism - Low-energy rotational force and some axial compression
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Soft tissue - Little soft-tissue injury
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Bone - Little articular comminution
High-impact pilon fractures have the following characteristics:
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Mechanism - High-energy axial compression
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Soft tissue - Extensive soft-tissue injury
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Bone - Severe articular and metaphyseal comminution
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Low-energy pilon fracture in distal tibia with no significant displacement.
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Lateral view of pilon fracture.
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Low-impact pilon fracture with displacement but without significant comminution.
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Lateral view of pilon fracture.
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Significant comminution and displacement of fracture fragments in pilon fracture.
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Lateral view of pilon fracture.
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Soft-tissue trauma, with blister and area of pressure necrosis over medial aspect of distal leg, in patient who presented 48 hours after injury.
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Significantly displaced medial malleolar fragment responsible for area of pressure necrosis.
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Lateral radiograph of pilon fracture.
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Necrotic area is excised, and bead pouch covers wound.
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Wound on medial aspect of ankle after 8 days.
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Split skin grafting of wound.
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Pilon fracture stabilized by minimally invasive technique.
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Pilon fracture stabilized with cannulated screws.
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Patient with full active plantarflexion at 2-year follow-up after pilon fracture surgery.
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Picture at 2-year follow-up after pilon fracture surgery showing full active dorsiflexion.
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Patient at 2-year follow-up after pilon fracture surgery.
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Pilon fracture showing significant comminution and displacement.
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Lateral radiograph of pilon fracture.
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External fixator stabilizing pilon fracture. Swelling has resolved, and blisters have healed.
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External fixator maintaining improved alignment of pilon fracture.
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Alignment in lateral view of pilon fracture, stabilized in external fixator.
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CT scan showing multiple fragments in articular dome of pilon fracture.
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CT scan showing axial cut of pilon fracture.
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Minimally invasive plating technique performed as second stage in treatment of pilon fracture.
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Lateral view after minimally invasive plating of pilon fracture.
