AP radioraph of a pilon fracture in a spanning external fixator demonstrates transverse fibula fract

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AP radioraph of a pilon fracture in a spanning
external fixator demonstrates transverse fibula
fracture at the level of the tibia fracture.
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IMPACTED ARTICULAR SURFACE
ANTEROLATERAL FRAGMENT
The displaced anterolateral fragment and the
impacted anterior articular fragment are visible
on the AP x-ray.
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The lateral radiograph demonstrated significant
impaction of the anterior articular surface
(arrows).
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The CT scan identifies the major posteriomedial
fragment as well as the displaced anterolateral
fragment and the void from where the impacted
articular segment was displaced.
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ARTICULAR VOID FROM IMPACTION
ANTEROLATERAL FRACTURE
The CT scan identifies the major posteriomedial
fragment as well as the displaced anterolateral
fragment and the void from where the impacted
articular segment was displaced.
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Surgery for the plafond fracture is always
deferred until the soft tissue injury appears to
be resolving. In this case, a standard anteromedi
al incision is chosen, which is placed medial to
the palpable tibialis anterior tendon.
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TIBIALIS ANTERIOR
JOINT LINE
MEDIAL MALLEOLUS
Surgery for the plafond fracture is always
deferred until the soft tissue injury appears to
be resolving. In this case, a standard anterolate
ral medial incision is chosen, which is placed
medial to the palpable tibialis anterior tendon.
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TIBIALIS ANTERIOR
JOINT LINE
MEDIAL MALLEOLUS
It is important when performing this approach
that the tendon sheath not be violated and that
the incision is medial enough to the sheath to
protect it in its entirety.
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The incision is brought down directly to bone
medial to the tibialis anterior tendon sheath,
which is within the soft tissue sleeve.
The impaction of the anterior articular surface
leaves a large void adjacent to the talar
articular surface.
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TIBIALIS ANTERIOR WITHIN SOFT TISSUE
IMPACTED FRAGMENT
VOID ABOVE JOINT
The incision is brought down directly to bone
lateral to the tibialis anterior tendon sheath,
which is within the soft tissue sleeve.
The impaction of the anterior articular surface
leaves a large void adjacent to the tail of the
articular surface.
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A no-touch technique is utilized with
self-retaining retractors, allowing access to the
intraarticular displacement. The two articular
fragments, including the impacted articular
fragment, are visible with medial retraction of
the plafond.
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IMPACTED FRAGMENT
ARTICULAR FRAGMENT
A no-touch technique is utilized with
self-retaining retractors, allowing access to the
intraarticular displacement. The two articular
fragments, including the impacted articular
fragment, are visible with medial retraction of
the plafond.
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A no-touch technique is utilized with
self-retaining retractors, allowing access to the
intraarticular displacement. The two articular
fragments, including the impacted articular
fragment, are visible with medial retraction of
the plafond.
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A no-touch technique is utilized with
self-retaining retractors, allowing access to the
intraarticular displacement. The two articular
fragments, including the impacted articular
fragment, are visible with medial retraction of
the plafond.
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The impacted articular surface, which is easily
visualized on the lateral radiograph must be
reduced down to the normal position of the
joint.
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This is normally performed by placing a curved
osteotome above the attached cancellous bone of
the articular segment and forcefully manipulating
the fragment distally against the talus as a
template.
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CURVED OSTEOTOME
IMPACTED FRAGMENT
The curved osteotome is reducing the impacted
articular fragment down against the talus
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BONE TAMP
A bone tamp can be used to support the articular
surface against the talus while fixation is
performed, typically with a lag screw or push
plate.
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The joint is now well reconstructed anteriorly
and medially. A lag screw has been used to fix
the anterior impacted fragment and a medial push
plate has been used to support the anteromedial
cortical rim.
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MEDIAL PUSH PLATE
PLAFOND
LAG SCREW
TALUS
The joint is now well reconstructed anteriorly
and medially. A lag screw has been used to fix
the anterior impacted segment and a medial push
plate has been used to support the anteromedial
cortical rim.
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The joint is now well reconstructed anteriorly
and medially. A lag screw has been used to fix
the anterior impacted segment and a medial push
plate has been used to support the anteromedial
cortical rim.
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MEDIAL PUSH PLATE
PLAFOND
LAG SCREW
TALUS
The joint is now well reconstructed anteriorly
and medially. A lag screw has been used to fix
the anterior impacted segment and a medial push
plate has been used to support the anteromedial
cortical rim.
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After reduction of the impacted articular
segment, several small fragments of bone,
including cortical fragments and another
articular segment, were removed from between the
impacted articular surface and the anterolateral
fragment.
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A pointed reduction clamp will then be used to
reduce the anterolateral fragment to the
reconsrtructed anteromedial portion of the joint,
which has been reconstructed. A percutaneous
screw and an anterolateral push plate is then
used to support the reduction.
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TIBIA
AL FRAGMENT
TALUS
The reduction is anatomic and supported with two
low profile plates, one medially and one
anterolaterally.
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The reduction is anatomic and supported with two
low profile plates, one medially and one
anterolaterally.
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ANTERIOR PUSH PLATE
TALUS
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Closure is performed in layers, being careful to
protect the tibialis anterior paratenon and soft
tissue sleeve. The closure should be performed
with vertical mattress sutures of Danati without
tension. If any tension is present, relaxing
incisions or pie-crusting technique should be
utilized.
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AP and lateral radiographs demonstrating good
alignment and fixation of the plafond fracture.