Sirkin M, Sanders R. The treatment of pilon fractures. ... Pediatric Radiology, Vol. Melone classification. Agreement at the group level with the AO system remained poor (kappa = 0.38). Petit P, Panuel M, Faure F. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. Journal of Pediatric Orthopaedics, Vol. Tibial and Fibular Shafts Chapter 6 included proximal tibial fractures. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. Pictorial Review: Cross-Sectional Imaging of the Foot and Ankle. Classification. They should not be confused with an insufficiency fracture, which occurs due to normal stresses on abnormal bone. Several factors contribute to increasing complexity in these injuries and include proximal fracture extensions, multiple articular fragments, impacted segments, bone loss, and osteopenia. Fractures of the distal tibia are among the most difficult injuries facing the orthopaedic traumatologist. 2009;192 (1): W7-12. The overall treatment approach typically consists of a staged protocol with primary restoration of tibial length followed by a delayed reconstruction of the articular surface.6,7 The basic principles outlined by Rüedi and Allgöwer8 over 35 years ago continue to direct our treatment of these injuries. It is important to realize that in these cases the radiographs of the ankle may be … Distal tibial physeal fractures can be described using a number of classification systems. 34.2).3 This classification system is much more detailed, describes comminution at multiple levels, and differentiates between partial and complete articular injuries. During provisional external fixation, the sagittal plane translational and angulatory deformities of the lower leg can also be improved with strategically placed bumps (beneath either the foot or the leg). This assists with resolution of soft tissue swelling, and it also ensures that the definitive open reduction will not require an acute intraoperative limb lengthening. AJR Am J Roentgenol. Frequently, the soft tissues are the most traumatized over the distal tibia, and avoidance of incisions in this region may prove prudent. Frequently adopted is the one proposed by Ruedi and Allgower 5: Derived from the French word pilon (pestle), an instrument used for crushing and pounding and usually used with a mortar. The indications for surgical treatment are based on the combination of fracture location, fracture pattern, and the associated soft tissue injury. Check for errors and try again. These injuries are frequently open, especially on the medial side where the distal tibia is in a subcutaneous location. A very useful tutorial on this topic can be found here.. Reference: Schatzker, J., et al. There are many ways to describe distal radial fractures and there are several classification systems. The Weber ankle fracture classification (or Danis-Weber classification) is a simple system for classification of lateral malleolar fractures, relating to the level of the fracture in relation to the ankle joint, specifically the distal tibiofibular syndesmosis. Fibular fixation is dependent on the location and the mode of failure. Stabilization of either or both the midfoot and the forefoot is still required to maintain the foot in neutral dorsiflexion. An understanding of the basic muscular and tendinous anatomy about the distal tibia and ankle joint is necessary to enable uncomplicated approaches and dissections in safe planes. The Weber classification focuses on the integrity of the syndesmosis, which holds the ankle mortise together. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification incorporates all fractures of the distal tibia, including extra-articular injuries of the distal tibial metaphysis (Fig. Classification of distal fibula fractures attempts to split fractures into groups by severity. In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. In clinical practice however frequently eponyms like Colles' and Barton's are used. If the open wound is large, proximal and distal extensions over the anteromedial face of the distal tibia should be avoided whenever possible. This classification can help dictate treatment as well as predict outcomes and rate of complications associated with individual fracture. 5. Publicationdate 2010-04-10. The position of the foot at the time of impact combined with the direction of the applied force will determine the resultant fracture pattern and articular impaction. A tibial plateau fracture classification system was developed in order to assess the degree of injury and the appropriate treatment for each type of fracture. indications closed low energy fxs with acceptable alignment < 5 degrees varus-valgus angulation Radiology Department of the Rijnland Hospital, Leiderdorp, the ... you need to understand the classification of ankle fractures and exorotation injuries that were highlighted in Ankle - Fractures 1 and 2. posterior malleolus fracture. Most articular fractures of the distal tibial weight-bearing surface are the result of motor vehicle accidents, motorcycle accidents, falls from heights, and industrial injuries. Some important principles include placement of all pins remote from any anticipated surgical incisions, avoidance of pin placements into the talus if any anterior exposure is planned, and pin placement into subcutaneous locations to minimize pin-site irritation and drainage. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? Consideration of tension versus compression failure has implications from a biomechanical standpoint when fixation is considered. In these cases, clamp application, fracture reduction, articular lag screw fixation, and plate application are all accomplished through the open wound without additional soft tissue stripping. 6-27), fibular head, and tibial tuberosity (see Fig. In addition, gross or micromotion at the fracture site should be minimized to allow the soft tissue swelling to resolve. Tibial plateau fractures may occur together with meniscal and ligamentous injuries to the knee. Limb exsanguination and tourniquet application assist with visualization within a bloodless field. After identification of all the fracture fragments on the CT scan, the findings can be correlated with the findings of the plain radiographs obtained after length has been reestablished. 166(5):1203-6. Alternatively, an ankle joint spanning external fixator (described later) may be used to provide some stability to the fracture. Chen SH, Wu PH, Lee YS. (1993) ISBN:0387558373. Fracture of metaphysis, epiphysis and epiphyseal line were noted separately for distal tibia. Tertius fracture - seen on AP view (red arrow) and on lateral view (yellow arrow). The value of CT scans in assisting with preoperative planning and fracture understanding has been well demonstrated.1 Similarly, contralateral ankle radiographs are frequently helpful in understanding the unique morphological variations in the distal tibial anatomy and assist with pre-operative planning. The articular impaction that is frequently associated with these injuries does not respond to ligamentotaxis and will therefore not be reduced with closed methods. The surgical approach for fixation of the fibula should be in a posterolateral location, posterior to the palpable back border of the fibula. 1996 May. However, for the purposes of describing these injuries and formulating a surgical plan, the fracture group (e.g., C1, C2, or C3) can be helpful. Stress fracture of the distal tibia post ORIF. Distal tibial physeal fractures are classified by the Salter-Harris classification.They can also be classified by the Rupture of the anterior syndesmosis - seen as widening of the space between the distal tibia and fibula (lateral clear space). 30 … For example, in displaced partial articular injuries (type 43B) of the distal tibia, nonoperative management is ineffective in reducing the displaced fragment in the majority of these injuries. [Medline] . 6. Radiographs made at presentation were unremarkable. 1 Using the principles of the Comprehensive Classification of Fractures of the Long Bones (CCF) developed by Müller and collaborators, the OTA classification committee classified and coded the remaining bones. Review of the fibular fracture characteristics, combined with the coronal plane angulation of the tibia, provides visual clues regarding the areas of compression and tension failure. The posterior tibial articular surface extends more distally, making a posterior arthrotomy for joint inspection impractical. 4. CT ankle for spiral distal third tibia fracture . Tibial spiral fracture (Toddler's Fracture) • nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age **Descriptive classification may also be used to further describe fracture patterns (greenstick, transverse, comminuted, oblique, spiral, etc. Several classification systems exist. Role of Magnetic Resonance Imaging in the Diagnosis of Distal Tibia Fractures in Adolescents. According to the 10th edition of “Campbell Orthopedic Surgery”, the term tibial plafond fracture, pilon fracture, and distal tibial explosion fracture have all been used to describe intra-articular fractures of the distal tibia. Indirect techniques to regain length may be necessary, especially in high-energy pilon fractures with significant shortening and soft tissue swelling. The initial surgical management of tibial pilon fractures requires planning for subsequent procedures based on the injury pattern, associated open wounds, and soft tissue swelling. Thereafter, progressive weight bearing and mobilization can proceed based on the patient′s comfort in applicable cases. Swelling occurs rapidly and may be exacerbated by the shortening that occurs. The anterolateral approach has the advantage of excellent visualization of the articular surface to the medial shoulder of the ankle while avoiding dissection of the anteromedial tibial face. Second, this provides a stable lateral column that a medially based external fixator can be tensioned against to correct any persistent shortening and angulation of the tibia. The AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification was published as a compendium to the Journal of Orthopaedic Trauma (JOT) in 1996. Nonoperative treatment of distal tibial fractures is recommended only for truly nondisplaced fractures or fractures in patients that have an absolute contraindication for surgical management. This can be a stage 2 of a Weber C fracture. Distal tibia fractures are complex injuries with a high complication rate. type II: displacement of the articular surface but with minimal or no comminution. Trauma Fractures of the tibial and fibular shafts are among the most common long bone… Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. In similar complete articular distal tibial fractures with an associated fibular fracture, shortening is expected with associated widening of the joint. Additionally, the external fixator should maintain the foot out of plantar flexion in a neutral position (Fig. [Medline] . The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. The Rüedi and Allgöwer classification of pilon fractures. Petit P, Panuel M, Faure F. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. In case of fracture, involvement of the articular surface, articular dehiscence and ridge formation, subluxation and number of tibial fragments were evaluated. The distal tibial fracture would be designated at “4.3” (e.g., 43-C2) injury, followed by the type and group classification above. KEY FACTS • The tibial pilon fracture is a rare, yet devastating injury. The axial images are the most useful and provide identification of the major articular fragments, cephalad articular impaction, and regions of comminution and fragmentation. The articulating distractor-compressor clamp can be used to regain length with a standard external fixator. 3. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior … A variety of instruments are helpful for reduction and fixation of pilon fractures (see text box). In the case of an intact fibula associated with a complete articular distal tibial fracture, varus angulation commonly occurs, and closed methods must counteract this tendency. External fixation combined with open reduction and internal fixation (ORIF) of a fibular fracture. The relevant anatomy of the talus includes an understanding of the nonarticular portions because these can be used for placement of Schanz pins that are useful in distraction across the ankle joint. Major fractures of the pilon, the talus, and the calcaneus, current concepts of treatment. Although certain injury patterns may suggest a predominantly osseous injury to the knee, others may suggest significant soft-tissue injury. Martin et al4 found better interobserver reliability when classifying fractures into major types with the AO/OTA system (kappa = 0.60) than with that of Rüedi and Allgöwer (kappa = 0.46). {"url":"/signup-modal-props.json?lang=us\u0026email="}. Equipment Used for Open Reduction and Internal Fixation of Pilon Fractures, Medium femoral distractor (used to distract between the talus and midshaft of the tibia to enable visualization of the distal tibial articular surface), Kirschner wires (K-wires) of varying sizes, 2.5-mm terminally threaded pins as joysticks, Small-fragment screws (2.7 and 3.5 mm; with long lengths, e.g., 60 to 80 mm), Mini-fragment screws (2.0 and 2.4 mm; with long lengths, e.g., 40 mm), Headlight to visualize the articular surface, Multiple plates consistent with the screws and preoperatively planned bone tamps, Allograft bone chips (as necessary) versus a bone graft substitute. An exception to this is the situation where the surgeon wishes to internally fix the “simple” articular injury through the traumatic open wound as already noted. Isolated distal fibula fractures account for up to 55-65% of all ankle fractures (4). Lower Extremity Danis – Weber Classification of Ankle Fractures; Classification: Description: Notes: Type A: Fracture distal to ankle joint: Often avulsion. Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. If open reduction is anticipated, reestablishment of the length of the tibia and fibula is necessary. Fibular fixation (if fractured) is a necessary component of the initial surgical management for three reasons. Transverse fractures at the ankle joint line are the result of tension forces on the fibula. Despite the best treatment, patients sustaining high-energy pilon fractures generally do not return to their previous state of general health or function. Fracture blisters, local skin necrosis, and impaired distal perfusion are commonly observed. 34.7). Previous ORIF complicated by … The cross-sectional anatomy of the distal tibia demonstrating the relevant neurovascular structures and their relationship to the surgical approaches. The Salter-Harris classification is commonly used and easily applied to these fractures. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The deep peroneal nerve and the anterior tibial vessels are located between the EHL and EDC distally, requiring direct identification and protection in the direct anterior approach. Additionally, a posterolateral incision is not located directly over the subcutaneous fibula, helping to minimize wound complications in this location. Classification of femoral shaft fractures is straightforward. Other closed methods such as calcaneal traction may allow serial soft tissue evaluations and provide some joint distraction and ligamentotaxis, but patient compliance and prolonged bed rest are required. Pain left tibia. The distal tibial articular surface is centrally concave with associated posterior and anterior extensions. The Weber criteria relates the position of the distal fibula fracture to the syndesmosis (4). Frequently, the important ligaments of the ankle remain largely intact after a pilon fracture, producing the commonly observed major fracture segments consisting of the posterolateral (Volkmann′s) fragment, the anterolateral (Chaput) fragment, and the medial fragment. There are many different classifications used for these fractures. Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (distal tibiofibular syndesmosis, deltoid ligament) and/or fracture of the medial malleolus. The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes Displaced or unstable extra-articular distal metaphyseal fractures can be effectively treated with several surgical techniques, including external fixation, open reduction and plate fixation, percutaneous reduction and minimally invasive plate fixation, medullary nailing, or combinations thereof. Such injuries can be effectively managed with closed reduction and cast immobilization followed by progressive weight bearing and ankle range of motion as radiographic healing progresses. For the purpose of this review, we will use the Danis-Weber criteria for lateral fibula fractures. Casting is ineffective in reducing any displaced articular segments, and distraction across a shortened ankle joint is not feasible with this treatment method. After placement of the proximal 5-mm bicortical tibial pin (perpendicular to the anteromedial face of the tibia) and the 5-mm calcaneal tuberosity pin (parallel to the distal tibial coronal plane articular surface), length and coronal alignment can be obtained. first branch of popliteal artery; passes between 2 heads of tibialis … Introduction. Nondisplaced fractures may similarly require operative fixation if early motion of the ankle is desired. The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI). Arch Orthop Trauma Surg. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The fibula extends distally relative to the tibia, and is firmly attached by the anterior and posterior tibiofibular ligaments. Inability to bear weight for 4 steps both immediately and in the emergency department. Although the anterior tibia extends over the dome of the talus, the entire articular surface of the tibia can be viewed from any of the anteriorly based approaches. The other criteria commonly used is the Lauge-Hansen classification. When these epomyms are used, an accurate description of the fracture characteristics should always be included in the report(5). Similarly, because of the intimate articulation between the tibia and fibula at the distal tibiofibular joint, angular deformity of the distal fibula in any plane will have implications on the tibial reduction. However, the prerequisites of such an approach include the following: A complete understanding of the injury, the fracture pattern, and the associated articular involvement, Confidence that a thorough debridement of the open injury has been done in a timely manner, An understanding of the techniques through which the surgeon can reduce and internally fix portions of the injury with “minimally invasive” methods, A well-rested and appropriate surgical team. Anatomy of pilon fractures of the distal tibia. Standard tibial plateau fractures involve cortical interruption or depression or displacement of the articular surfaces of the proximal tibia without concomitant significant injury to the capsule or ligaments of the knee (,1). In some highly comminuted fibular fracture patterns that are not amenable to direct reduction techniques, indirect reduction of the fibula is accomplished. If scans are inadvertently obtained prior to reestablishment of tibial length, they frequently need to be repeated because the overall position of the fragments changes significantly. North Am. The indications for nonoperative management of displaced, articular tibial pilon fractures are extremely limited. However, the reproducibility and usefulness of this classification system have been questioned. There are other, often more subtle, fractures about the knee. These muscles are all innervated by branches from the peroneal nerve proximally in the leg, enabling distal approaches that are medial, lateral, and between these muscles. Swiontkowski et al5 demonstrated that only moderate agreement (kappa = 0.41 to 0.60) existed with the AO/OTA system, and that determination of the fracture type alone (type A, B, or C) was probably adequate for clinical research. If any of these prerequisites for this approach are not met, then a staged protocol consisting of primary fibular plating and external fixation across the ankle joint combined with further debridement and wound closure at a secondary procedure is indicated. 1-2. In this retrospective and multicentre study we attempted to detail complications and outcomes of this type of injury in order to determine predictive factors of poor results. The tibial nerve and the associated vascular supply posteriorly require protection and identification during posteromedial surgical exposures (Fig. The system that comes closest to directing treatment has been devised by Melone. Classification. The use of a tourniquet in articular fractures of the distal tibia is not optional and is preferred in most circumstances. Similar trends were noted when evaluating intraobserver reliability. Bone scintigraphy 2 weeks later shows stress fractures of the distal … Although both extra-articular and intra-articular patterns occur with varying severity, the common concern in all of these injuries is the associated soft tissue injury. First, an accurate reestablishment of the proper fibular length and rotation indirectly reduces the tibia due to the strong ligamentous attachments, as already noted. For example, if the original injury film demonstrates significant varus angulation of the distal tibia, a medial buttressing implant is likely indicated to counteract the inherent tendency for this injury to fail back into varus. Plain radiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. Cheung Y, Perrich KD, Gui J et-al. 34.1). Stress fractures of the fibula typically occur in the distal one-third. Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands Publicationdate 2012-08-23 Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint. anterior tibial artery . The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes The superficial peroneal nerve is purely sensory and travels from posterior to anterior, crossing the anterolateral surgical incision (Fig. Some of these are included in the OTA type A1 category, which includes avulsion fractures of the tibial spine (see Fig. Chapter 8 will review distal fractures about the ankle. Although there are several classification systems, a descriptive classification is the most useful and includes fracture location (proximal, middle, or distal), pattern (simple, wedge butterfly, or comminuted), and whether the fracture … Haapamaki VV, Kiuru MJ, Koskinen SK. The sagittal and coronal reformations provide additional data, especially for identifying impacted segments that are rotated relative to the axial images. This chapter will focus on the shaft of the tibia and fibula with respect to fracture management and leg length discrepancy. Presentation. After recovery from pilon fractures, many patients continue to … )** Multiple approaches have been suggested, but there is no consensus regarding the optimal treatment for these injuries and no long-term outcome measures that define the results of either the injury or the treatment. On the basis of plain radiographic findings, the prevalence of liga… 2, 3 This … Finnish statistics 1970- 2000 and projections for the future. Beebe MJ, Auston DA, Quade JH, Serrano-Riera R, Shah AR, Watson DT, et al. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. Ankle and foot injuries: analysis of MDCT findings. In these instances, no attempt is made to reduce every small cortical fragment, but simply to correct length, rotation, and angulation of the distal fibula. Significant joint stiffness is expected after the closed treatment of pilon fractures because healing in an acceptable position requires prolonged joint immobilization. Impaction at the medial shoulder is difficult to reduce with this exposure. Topliss CJ, Jackson M, Atkins RM. The FHL has a very distal muscle belly, and its identification is especially useful in the posterolateral approach to the distal tibia. On the left an athlete with pain just above both ankles, more pronounced on the left than on the right. Trauma Radiology Reference Resource; 11. Any surgical approach chosen should respect any remaining ligamentous attachments to these structures. These are considered to represent 1-10% of all lower limb fractures 6. This can be corrected via the following: Manual traction, distracting between the proximal tibial and distal calcaneal pin, Use of the articulating distractor-compressor clamp, which can aid in gaining length in a controlled manner (Fig. 20, No. A combination of newer surgical techniques emphasizing meticulous soft tissue handling, limited approaches, and low-profile periarticular implants have enabled avoiding the common soft tissue problems that followed medial plating historically. Group: Tibia, distal end segment, complete, multifragmentary articular and metaphyseal fracture 43C3 Qualifications are optional and applied to the fracture code where the asterisk is located as a lower-case letter within rounded brackets. tibia . Fatigue fractures (also known as overuse fractures) are a type of stress fracture due to abnormal stresses on normal bone. Proximal extension of the incision is limited as well. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior … Distal Radius = 17% …Metacarpals = 11% …Proximal femur = 11% Figure 3-3 Distal Radius Tibial shaft Ankle M F Ankle fractures are increasingly common Figure 59-1 Incidence of ankle fractures in older women Kannus et al. Tibiofibular ligaments intact: Type B: Fracture at the level of the Tibiofibular ligaments 2. 1. The anticipated pin locations are at the medial tuberosity of the calcaneus, transversely in the midfoot into the cuneiforms, and at the anteromedial face of the tibia (two pins) proximal to any subsequent plate applications. This frame configuration is especially useful in patients who are treated late (and require bilateral distraction to regain length) and in those injuries where the fibula cannot be fixed at the initial operative procedure. Computed tomography (CT) scans should be delayed until limb length has been restored. Although some flexibility in treatment is important in these injuries, these tenets remain a good starting point during the formulation of an operative strategy. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Proximal Humerus Fractures and Shoulder Dislocations. The relevant osseous anatomy of the tibial pilon includes the distal tibia, the distal fibula, and the talus. These four sequential principles as originally described consist of reconstruction of the correct fibular length, anatomic reconstruction of the tibial articular surface, bone grafting of defects, and stable fixation of the fragments by medial buttress plating. - seen as widening of the conventional radiographs and the associated comminution increase application assist with visualization within bloodless... 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