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), Core Knowledge in Orthopaedics: Foot and Ankle. Small wire epiphyseal-diaphyseal ring fixators were then employed to treat pilon fractures to allow for early ankle motion in an effort to minimize long-term ankle stiffness. This is still an emerging technique, and the risk of opening a pilon fracture during the initial stages of swelling could be devastating. Two main classifications are used, which use different criteria for grouping. The series reported by Ruedi and Allgower described superior outcomes after formal open reduction and internal fixation (ORIF) in their patient population with few major complications. AO Surgery Reference is an internet-based resource for the management of fractures, based on current clinical principles, practices and available evidence. The superficial peroneal nerve pierces the fascia of the lateral compartment ~ 12 cm proximal to the ankle joint en route to provide sensation to a majority of the dorsum of the foot. 1/3 of patients have associated injuries . At the level of the ankle, the distal tibia is intimately associated with the fibula through strong ligamentous attachments. Learn more. METHODS: One senior attending, two fellows (one trauma, one foot and ankle), one junior orthopaedic resident, and one experienced research coordinator independently classified eighty-four sets of radiographs. The systems used to classify the displaced distal pilon fractures are supposed to ensure the three-dimensional assessment of the fracture and provide high inter- and intra-observer agreement. New research was undertaken to determine the best way to manage higher energy fractures of the tibial plafond in response to the higher rates of infection. Tibialis posterior tendonopathy/adult acquired flatfoot, 43A: extra-articular – most would not recognise these as pilon fractures, although in some series non-articular fractures are included and it can be difficult to tell how many were articular, 43B: partial articular fractures with some connection between part of the joint surface and the diaphysis - again, some series appear to include these but most do not clearly differentiate between them and those with complete separation between diaphysis and metaphysis. 1a-c). The distal tibia is designated as #43 (4 = tibia, 3 = distal segment). The AO Spine classification of thoracolumbar injuries is one of the more commonly used thoracolumbar spinal fracture classification systems and aims to simplify and universalise the process of classifying spinal injuries and improve interobserver and intraobserver reliability 3.. Insert figures illustrating the classification. AO Classification of Distal Tibial Fractures A – extra-articular (metaphyseal fracture) ... high energy pilon fractures will take about 4 months to heal; 75% may expect good result (if no wound complications) 2000 Jul-Aug. 8 (4):253-65. The pilon fracture usually has an anterolateral (Chaput) fragment and a posterolateral (Volkmann) fragment, which usually remain attached to the distal fibula segment by the anterior and posterior tibiofibular ligaments. "AO" is an initialism for the German "Arbeitsgemeinschaft für Osteosynthesefragen", the predecessor of the AO Foundation. J Am Acad Orthop Surg. The concave tibial plafond provides ~ 40% more posterior than anterior coverage. 20-25% are open . Figures. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on … After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness (Babis et al 1997, Sands et al 1998, Pollak et al 2003). The Tscherne scheme has 4 grades of increasing severity for soft tissue injury in closed fractures. METHODS: One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. These classifications are less reproducible and do not provide necessary information for proper surgical planning. fixation. Background Distal tibia fracture with intra-articular extension . According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. In publications, it will be cited as Meinberg E, Agel J, Roberts C, et al. C2 pilon fracture treated with the MIPO technique. Classification of distal tibial fractures AO Classification. The tibial pilon fracture is a rare, yet devastating injury. Thordarson DB. The Topliss classification was more reproducible, especially in the hands of Topliss herself, although no statistical analysis is provided. Pilon fractures treated with a cast have led to poorer outcomes than those managed operatively. Distinguish from pilon fractures—a higher energy injury caused by vertical impaction . The results of the classic study from the Swiss AO group could not, however, be reproduced by all surgeons. AO Classification of Distal Tibial Fractures A – extra-articular (metaphyseal fracture) ... high energy pilon fractures will take about 4 months to heal; 75% may expect good result (if no wound complications) Fractures of the distal tibia have been given the number 43 in the AO Classification (Fig. Principle 3: Metaphyseal bone defects are bone grafted to buttress the articular surface. 1) Muller-AO Classification of distal humeral fractures (also called just Muller or AO or OTA) Similar to AO classification of distal radius A- Extra-articular fracture (Supracondylar) Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. Reports describing ORIF of tibial pilon fractures revealed a concerning complication rate with higher energy pilon fractures, including wound problems, deep infection, nonunion, and malunion (McFerran et al 1992, Teeny and Wiss 1993). The pilon fracture usually has an anterolateral (Chaput) fragment and a posterolateral (Volkmann) fragment. University of California at Davis Medical Center . 110.2 ) … When the fibula was fractured, nearly 70% were type C complete articular fractures and over half were type C3, the most comminuted. Fracture classification. This new comprehensive AO CMF classification system for fractures in the adult craniomaxillofacial skeleton is organized in anatomic modules in a three precision-level hierarchy with a brief account of increasing complexity and other details: Level-1 Most elementary. The AO classification of clavicular fractures along with the Neer classification system is one of the more frequently used classification systems when assessing distal clavicular fractures.. Complications after treatment of tibial pilon fractures: prevention and management strategies. The dorsalis pedis and deep peroneal nerve are at risk with an anterior exposure. Abstract Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. Plafond is also a French term, described by Bonin, referring to the distal tibial articular surface as the roof (ceiling) of the ankle joint. Login. This relatively rare injury (< 10% of lower extremity fractures) usually occurs in adults (aged 30s to 40s) owing to a fall from height or a motor vehicle crash [ 6 ]. Gustilo type 1 open fractures are generally clean with a < 1-cm skin laceration. . Leg compartment syndrome should be diagnosed based on clinical examination and confirmed if necessary with compartment pressures. Fracture and Dislocation Classification Compendium–2018, Journal of Orthopaedic Trauma. Appreciate the consistent Y pattern creating 3 main articular fragments. Examination should document the presence of both closed and open soft tissue injury as well as location and extent of lacerations, abrasions, and contamination. Type-III fractures are the most frequent presentation, comprising approximately 25% to 71% of all pilon fractures. Impaction most commonly occurs at the dome between the 3 main fracture fragments. Type 3A open fractures have adequate soft tissue coverage over the fracture. Day 0. A severely traumatized soft tissue envelope accompanies the higher energy pilon fractures. Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for … Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. There may be some benefits to this technique with possibly less swelling and stiffness. 2013 Jul. In addition to the classification of Rüedi and Allgöwer, the classification of pilon fractures has been carried out using the AO classification. none have been shown to be superior with respect to ankle stiffness; 2 tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin 2013 Jul. Explore AO Trauma's varied teaching and learning materials to enhance your expertise. These principles (perhaps with #3 optional), restoration of articular surface, realign joint surface to shaft, then bridge metaphyseal comminution with fixation, can be applied to any periarticular fracture. The 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium for adults and children addresses the many suggestions to improve the application of the system, as well as add recently published and validated classifications. Understanding the soft tissue injury accompanying pilon fractures is of utmost importance for providing optimal treatment while minimizing complications. Fracture lines were mapped from axial CT cuts 3 mm above the plafond after an external fixator had been applied. Pilon is a French term used to describe a fracture of the distal tibia usually characterized by high-energy traits, including dissociation of the articular surface from the tibia shaft. In publications, it will be cited as Meinberg E, Agel J, Roberts C, et al. six typical fragments, recognition of which helps plan reconstruction - not all present in any one patient: three main groups of fractures based on the main orientation of the fracture lines: coronal group, typically lower-energy fractures in older patients with a more distal metaphyseal-diaphyseal dissociation and valgus alignment (56%), sagittal group, typically higher-energy fractures in younger patients with a more proximal metaphyseal-diaphyseal dissociation and varus alignment (33%), comminuted fractures of such severity that they could not be assigned to any group (6%), a group of fractures ("lateral disruption fractures") with incongruity of the joint between the lateral malleolus and the lateral talar facet, often with an intact fibula. Matthew Tomlinson. RESULTS: This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60) years. When the fibula was intact, 58% of fractures were partial articular type B. External fixation alone became popular for managing complex pilon fractures associated with both closed and open compromised soft tissue envelopes. The theoretic teachings will be put into practice by each participant on anatomical preparations. 1-10% of LE fx’s . They should facilitate communication among physicians and be useful for … A systemic motor and sensory examination is warranted in addition to documentation of distal pulses. Surgical indications for operative fixation of pilon fractures include open injuries, 2 mm of articular displacement, talar subluxation, or malalignment greater than 5 degrees. What is the most appropriate Gustilo-Anderson classification of this injury? Pilon fractures can occur from both low- and high-energy mechanisms. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2) Techniques: External fixation. According to the Fernandez classification, 26 patients (76%) had type 5 fractures, and 8 patients (24%) had type 3 fractures. Management selection. The most widely accepted open fracture classification is credited to Gustilo and Anderson. According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. These can be challenging to manage, especially when associated with significant soft-tissue injury. Type A fractures are extraarticular distal tibial fractures, which are subdivided into groups A1, A2, and A3, based on the amount of metaphyseal comminution. 2000 Jul-Aug. 8 (4):253-65. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. Axial CT shows fracture lines dividing the plafond into 3 major fragments: Anterolateral, posterior, and medial. 2000 Jul-Aug. 8 (4):253-65. Collectively, these 2 maps aid the surgeon in predicting necessary surgical tactics and approaches. Low-energy fractures typically occur due to rotational forces imparted to the distal tibia. The most widely used classification systems for pilon fractures are Ruedi-Allgower and AO (Arbeitsgemeinschaft für Osteosynthesefragen) , but concern has been raised over the accuracy and reproducibility of these 2 classifications (7, 8), which are X-ray based. Open fractures with vascular injury requiring repair along with extensive soft tissue compromise are considered type 3C. The first sub-grouping is on the degree of cntinuity between diaphysis and metaphysis: 1. Comminution, which frequently occurs with high-energy pilon fractures, is most typically located in the anterolateral and central regions of the plafond. More educational tools. 43B: partial articular fractures with some connection between part of the joint surface and the diaphysis - again, some series appear to include th… The AO group has developed a comprehensive classification of fractures. Thordarson DB. 236. Thordarson DB. The Müller AO Classification of fractures is a system for classifying bone fractures initially published in 1987 by the AO Foundation as a method of categorizing injuries according to therognosis of the patient's anatomical and functional outcome. . 4. The AO long bone group universal classification of fractures groups distal tibia fractures as 43. Pilon fractures in the distal tibia result from axial forces that can range from low to high energy and produce a spectrum of articular and metaphyseal injuries. The fractures are divided into types and further into groups then subgroups. . Classification of distal tibial fractures AO Classification. tension band. The tibial pilon fracture is a rare yet devastating injury. In this group there was always a tibial fragment remaining in the correct relationship to the fibula which could be used to help judge reduction, but failure to recognise and reduce talofibular incongruity led to poor results. There are also multiple small, comminuted fragments. Complications following surgical management of pilon fractures, particularly wound breakdown, were historically common. The tendons of the anterior compartment, the dorsalis pedis artery, and the superficial and deep peroneal nerves can be encountered with anterior exposures at the level of the ankle joint. 27(7):e152-6. Sclerosis is due to impacted bone fragments/trabeculae. joint-spanning articulated vs. nonspanning hybrid ring. When the ankle is dorsiflexed at the time of injury, pilon fracture patterns involve the anterior articular surface of the tibial plafond. Once the swelling has peaked and regressed 1-3 weeks after injury, open reduction of the tibia (and fibula) can be performed with removal of the temporary external fixator. Wound complications can be minimized with appropriate treatment strategies and soft tissue handling. Destot coined the term pilon, as he thought that the distal tibial metaphysis resembled a pharmacist’s pestle. 27(7):e152-6. All fractures were OTA/AO type 23C3. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. AO/OTA Fracture and Dislocation Classification Long-bone Fractures 41B Partial articular 41B1 Split 41B2 Depression 41B3 Split depression 41C Complete articular 41C1 Simple articular, simple metaphyseal 41C2 Simple articular, wedge, or multifragmentary metaphyseal 41C3 Fragmentary or multifragmentary metaphyseal 43A Extraarticular 43A1 Simple C. Discussion. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. The quality of reduction with external fixation alone was suboptimal, leading to poor outcomes secondary to joint arthrosis. . The AO long bone group universal classification of fractures groups distal tibia fractures as 43. Complications after treatment of tibial pilon fractures: prevention and management strategies. The compendium is branded as the AO/OTA or OTA/AO Fracture and Dislocation Classification Compendium. 27(7):e152-6. Spectrum of injuries: 1) Low energy rotational fx’s Ankle type fractures / Skiing, simple falls . Treatment of pilon fractures remains challenging due to the difficulty of fracture reduction and associated soft tissue complications. Type 2 open fractures have more extensive soft tissue injury with minimal to moderate crushing, typically with a laceration > 1 cm. We help you diagnose your Distal tibia case and provide detailed descriptions of how to manage this and hundreds of other pathologies Dear Visitor, Your browser is currently not set to accept cookies. Computed tomography (CT) examination is best delayed until restoration of length in shortened fractures because ligamentotaxis helps to better approximate fragments closer to their native position, making interpretation easier. Although the Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) classification system is the most widely accepted fracture classification system, the Ruedi-Allgower system is the classic fracture scheme often known and used for this injury throughout the world. Principle 1: Length and rotation is restored by ORIF of the fibula. Classification. Complications after treatment of tibial pilon fractures: prevention and management strategies. J Orthop Trauma. Classification systems have been developed to stratify both severity of fracture pattern and soft tissue injury. The Müller AO Classification of fractures is a system for classifying bone fractures initially published in 1987 by the AO Foundation as a method of categorizing injuries according to therognosis of the patient's anatomical and functional outcome. In: OrthopaedicsOne - The Orthopaedic Knowledge Network. Soft tissue injury has been standardized using the method of Tscherne for closed fractures and the Gustilo-Anderson classification for open injuries. The operative principles described by the AO group for operating pilon fractures serves as a working paradigm for ORIF of these injuries. The 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium for adults and children addresses the many suggestions to improve the application of the system, as well as add recently published and validated classifications. Fracture classification. AO Surgery Reference is a resource for the management of fractures, based on current clinical principles, practices and available evidence. Principle 4: Buttressing of the tibial metaphysis is then required while connecting the articular block to the diaphysis. Other common complications seen following treatment of tibial pilon fractures are arthrofibrosis and posttraumatic arthritis. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. These are considered to represent 1-10% of all lower limb fractures 6. Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. Type A is extra-articular, type B is partially articular, and type C is completely articular. Posterior partial fracture overlap with malleolar fractures with posterior malleolar components (Klammer 2013), and anterior partial fractures were included by Lauge-Hansen (1950) iin his classification of malleolar fractures, 43C: complete articular fractures with no connection between the joint surface and diaphysis – most pilon fractures fall into this group, 43C1: no comminution of epiphysis or metaphysis, 43C2: comminution of metaphysis but not epiphysis, 43C3: comminution of epiphysis +/- metaphysis (corresponding roughly to Ruedi-Allgower group III, many pilon fractures are in this category). 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