Pilon Fracture S82.873 823.80

synonyms: Tibial Plafond Fracture, pilon fracture, weight bearing surface of distal tibia fracture

Pilon Fracture ICD-10

• S82.871 Displaced pilon fracture of right tibia
• S82.872 Displaced pilon fracture of left tibia
• S82.873 Displaced pilon fracture of unspecified tibia
• S82.874 Nondisplaced pilon fracture of right tibia
• S82.875 Nondisplaced pilon fracture of left tibia
• S82.876 Nondisplaced pilon fracture of unspecified tibia

Pilon Fracture ICD-9

• 823.80(closed fracture of unspecified part of tibia)
• 823.81(closed fracture lower leg NOS; fibula alone)
• 823.82 (closed fracture lower leg NOS; fibula with tibia)
• 823.90(open fracture of unspecified part of tibia)
• 823.91(open fracture of unspecified part fibula alone)
• 823.92 (Unspecified part, open, fibula with tibia)

Pilon Fracture Etiology / Epidemiology / Natural History

• Pilon fractures are fractures involving the articular weight bearing surface of the distal tibia.
• Usually high energy axial load (MVC, fall from height), occasionally low-energy rotation/torsion
• Foot postion determines fracture pattern: if plantar flexed = posterior tibial fragment, neutral = entire articular surface, dorsiflexed=anterior fragments
• 7-10% of tibial fractures

Pilon Fracture Anatomy

• Distal tibia fractures within 5cm of the ankle

Pilon Fracture Clinical Evaluation

• Assess vascularity by evaluating dorsalis pedis and posterior tibial pulses as well as distal capillary refill
• Evaluate Soft tissues. Open fracture classification.

Pilon Fracture Xray

• A/P, lateral and mortise views of the ankle; A/P, lateral tibia films
• CT scan indicated for pre-op planning,  CT scans should be done in traction with 3D reconstructions. (Buchler L, JOT. 2009 Mar;23(3):208)

Pilon Fracture Classification/Treatment

• Soft tissues injuries are classified according to Tscherne and Gotzen.
• Open fracture classified per Gustilo and Anderson.
• Principles of Treatment: restoration of fibular length, anatomic reduction of tibial articular surface, bone grafting of metaphyseal defects, medial buttress plating to prevent varus
• Treatment: initial fixation of the fibula with temporary spanning external fixation with delayed conversion to internal fixation when soft tissues permit, generally 14-21 days. CT scan should be performed in traction for pre-op planning.  See Pilon ORIF / Ex Fix Technique.
• Closed fractures may be placed in calcaneal traction and a Bohler-Braun frame.
• Open fractures/compartment syndromes should be taken to OR for external fixation / fasciotomy.  Consider 2-pin traveling traction. (one 6mm centrally threaded calcaneal pin and one proximal tibia pin at level of the fibular head with quadrilateral frame.)
• AO comprehensive Classification of Fractures of long Bones
• Ruedi Allgower Classification (Ruedi TP, Allgower M CORR 1979;138:105).
• Type A=extra-articular=@92% good/excellent results, Type B=partial articular=@85% good/excellent results, Type C=complete articular=@60% good/excellent results
• poor results associated with high-grade soft-tissue injury, >2mm articular incongruency, malalignment of mechanical axis >5degrees
• Reudi-Allgower Classification: Type I & II = 86% excellent to good results nonuniomn =7%, malunion=3%, wound dehiscence=17% Type II&III high energy=wound problems and deep infection uto 37%, malunion=23%, nonunion=27%.  Tscherne grades 0 or 1 best treated with AO/ASIF technique plating, femoral distractor often helpful for indirect reduction.
• Tsherne 2 & 3 and open fx best treated with limited open fixation(olive wires/canulated screws) for articular reduction and small wire circular external fixation.
• AO Classification

Pilon Fracture Associated Injuries / Differential Diagnosis

• 1/3 associated with concomitant fx or organ injuries
• 10-50% open injuries
• 3-9% eventually require arthrodesis due to secondary arthrosis

Pilon Fracture Complications

• Nonuion
• Malunion
• Infection
• Painful hardware
• Compartment Syndrome
• CRPS
• DVT / PE
• Heterotopic Ossification
• Wound breakdown
• Posttraumatic arthritis

Pilon Fracture Follow up  care

• nonweightbearing at least 6wks generally 12 weeks., Ankle and subtalar ROM exercises.
• ORIF = 6 wks slc
• external fixation = early ROM exercises, WB advanced at 6wks, FWB before removal, dynamize 1-2 wks before removal.  Average fixator time is 15wks.  Cast for 1-2wks after fixator removal.
• (Pollok AN, JBJS 2003;85A:1893).
• (Marsh JL, JBJS 2003;85A:287).

Pilon Fracture References

1. Marsh JL, Borrelli J Jr, Dirschl DR, Sirkin MS. Fractures of the tibial plafond. Instr Course Lect. 2007;56:331-52
2. Rockwood and Greens
3. Watson JT, Pilon Fractures, Clin Orthop, 375:78-90, 2000
4. Watson JT, Tibial Pilon Fractues, Techniques in Orthopaedics, 11:150-159, 1996
5. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999 Feb;13(2):85-91.
6. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999 Feb;13(2):78-84
7. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. JBJS 58A:453-458, 1976
8. Tsherne H, Gotzen L: Fractures with Soft Tissue Injuries. Monograph 1-58. Berlin, Springer-Verlag 1984.
9. Leone VJ, Ruland RT, Meinhard BP: The management of the soft tissues in pilon fractures.  Clin Orthop 1993;292:315-320.
10. Thordarson DB, complications of tibial pilon fx: prevention and management strategies/ JAAOS 2000;8:253
11. March JL, Bonar S, Nepola JV, Decoster TA, Hurwitz SR; Use of an articulated Ex Fx for fx of the tibial plafond JBJS 77AL1498:1995
12. Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study.  J Bone Joint Surg 1996;78A:1646-1657.