Foot & Ankle

Management

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Non-operative management is reserved only for low-energy, undisplaced articular fractures and patients who carry high risks of surgery (significant medical co-morbidities, low physical demands with an acceptable alignment of the fracture).

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Surgical Management

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Emergency Management

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In case of a low-energy rotational injury without soft-tissue compromise, it is usually safe to immobilise the extremity in a cast and plan for an early ORIF.

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High-energy pilon fractures usually are treated in two stages. Emergency management of closed fractures includes reduction of displaced fracture and temporary stabilisation with a bridging external fixator until soft tissues settle down (10-14 days) to allow definitive fixation (span, scan and plan approach, as above).

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Two major objectives in the management of these injuries include restoration of the articular surface and preservation of the soft tissue envelope to optimise osseous healing and minimise complications. Open fractures are managed as per BOAST guidelines. Multiply-injured patients are assessed and managed as per ATLS principles.

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The timing of fibular fixation is controversial, as an acute inappropriate incision placement for fibular fixation (to restore the length along with a bridging external fixator) can compromise subsequent approaches.

 

Definitive Management

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When soft tissue swelling and blisters settle, definitive fixation is undertaken. It is vital to understand the fracture anatomy before planning surgery through adequate imaging.

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Multiple options are described for definitive fixation of pilon fractures, but there is no level I evidence for their optimal management.

 

Surgical Approaches

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The distal tibia can be approached through different surgical intervals depending on the presence of an open wound, residual fracture blisters and the location of key fracture fragments.

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The anteromedial, anterolateral, anterior, lateral, posteromedial and posterolateral approaches have been described and used depending on the above factors and surgeon’s preference.

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There is no single surgical technique for these fractures and a step-wise reduction of fracture fragments, attempted restoration of the joint surface with K-wires, followed by stable internal fixation is performed.

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Open Reduction and Internal Fixation

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The restoration of the articular surface normally starts by opening the more anterior articular fragments to visualise the central and posterior fragments.

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The individual articular fragments are reduced from posterior to anterior, with provisional reduction performed with K-wires, and definitive fixation with two or three screws.

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When the articular reduction is achieved, multiple anatomical low profile locking or non-locking plates are available to connect the articular fragment to the tibia.

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As a general rule, fracture patterns that end with valgus failure and lateral compression (coronal patterns) are better fixed with anterolateral plating. Fracture patterns that end with varus angulation of the tibia with lateral tension failure and compression of the medial side (sagittal patterns) are better stabilised with medial buttress plates.

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Controversy exists regarding fibular fixation in pilon fractures. Ruedi and Allgower recommended fixing the fibula first to restore the length of the lateral column, followed by the rest of the fracture fixation. However, in cases of severe fibular comminution, restoring the length is difficult. In case of using an anterolateral approach, care should be taken to leave at least 6 cm skin bridge from the fibular incision.

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Lee et al. found a lower rate of malunion and ankle arthrosis in 6 years of follow-up when the fibula was fixed with plating compared to pin fixation. Rouhani et al. and Williams et al. found no clinical difference at 6-month and at 2-year follow-ups, respectively, in patients treated with ankle-bridging external fixation, with or without fibula plating. The plating group suffered more wound complications, and the non-plating group had more incidence of angular malunion.

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External Fixation with or without Limited ORIF

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Indications for an external fixation include severely comminuted fractures, large articular fragments reducible by ligamentotaxis, open fractures with significant soft-tissue injury or contamination and patients with co-morbidities. This can be utilised with or without a limited ORIF.

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Different configurations of external fixators can be used; however, most surgeons recommend at least two or three pins proximal to the fracture, inserted from different directions with a cross-braced frame, and at least two or three tensioned 2 mm wires in the articular portion.

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Many authors have reported the results of external fixation with limited ORIF to be comparable with ORIF alone. A meta-analysis by Wang et al., including the results of 9 studies (498 fractures), comparing these two techniques, reported that the rates of non-union, malunion, delayed union, infection, subsequent arthrosis and chronic osteomyelitis were comparable between groups.

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Pin-site infection has been reported to be a serious complication with prolonged external fixation. It can be controlled and managed with an integrated multidisciplinary approach. Deep infection rates vary significantly in the literature and are biased by a higher proportion of open injuries treated definitively with external fixation.

 

Papadokostakis et al. reviewed the merits of spanning versus non-spanning frames and found, in their systematic review, that the overall deep infection rate with non-spanning frames was 2.7% and in the spanning group was 3.9%.

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McDonald et al. retrospectively reviewed 13 pilon fractures, treated with non-bridging three-ring circular frame, with a minimally invasive approach to articular reduction. Eleven fractures healed by 16 weeks. There was one delayed union that required bone grafting and one non-union treated with an arthrodesis. There were no deep infections.

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Watson et al. reviewed 107 pilon fractures treated according to a staged protocol. Forty-one patients had ORIF with minimal incisions and low-profile implants, with most cases managed within 5 days of presentation. Sixty-four patients underwent limited internal fixation of the articular fragments through small incisions and fine wire external fixation as definitive management. For the type C fractures in both groups, there was a significantly higher rate of complications including non-union, malunion and wound complications. Some would argue that internal fixation when performed within 5 days of injury might have accounted for the higher complication rate, but this group was selected on the basis of the less severe soft tissue injuries.