Lecture ucmc pilon plafond fracture distal tibia
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1) Tibial plafond fractures involve injuries to both the bone and soft tissues of the distal tibia. They require anatomical reduction, stable fixation, and early mobilization to achieve the best outcomes. 2) Several surgical approaches can be used including anteromedial, anterolateral, and posterolateral. Small fragment plates and screws are typically used for internal fixation. Meticulous soft tissue management and wound closure are important. 3) While most patients experience some pain, many are able to return to work. Arthrosis is detected in about 50% of cases, but arthrodesis is rare. Outcomes improve over time, and patients should not be rushed into reconstruction without allowing for further
Lecture ucmc pilon plafond fracture distal tibia
- 1. Tibial Plafond/Pilon Fractures 2/2/2011
- 2. The Spectrum of Fracture
- 3. The Spectrum of Soft Tissue Injury
- 4. Relative Success vs Dismal Failure
- 5. The Soft Tissue Injury!! Red Blisters Clear Blisters Open Fracture
- 6. Terrible Injuries “Excellent Results” are rarely achieved Fair-Good results are the norm Outcomes are impossible to predict Treatment complications must be avoided
- 8. 2 yrs. Unusually good!
- 9. Tibial Plafond Fractures Fair to Good Results Are the Norm 1991 - anterior B-3 fracture
- 10. Fair to Good Results Are the Norm 6 months 3 years
- 11. Fair to Good Results Are the Norm 8 years Ankle score - 80 Works as a laborer
- 12. 5 years - no pain Case 1 ankle score 95
- 13. 6.5 yrs - miserable - Case 2 ankle score 45
- 14. Case 1 Case 2
- 15. Avg. age 35-40 Rare in children and elderly patients Males 3 x more common 3-9% of all tibia fractures Associated injuries 25-50% Increased incidence – Air Bags!!! Burgess et al JT 1995 Lower extremity injuries in drivers of air-bag equipped automobiles Save lives yes, but devastate the foot and ankle
- 16. Multiply injured patients with and without foot injuries ( 24 and 12 month follow ups) Dramatic differences in pain, function and health related quality of life
- 17. Ankle Soft Tissues Thin skin Absent muscle and adipose tissue Lack of deep veins Particularly vulnerable!
- 18. The soft tissues over the anteromedial tibia are vulnerable
- 19. Dense trabecular structure of distal tibia
- 20. Bone is viscoelastic Axial load is rapid Shift in stress strain curve Tremendous energy release
- 21. Displacement Rapid axial load Note the greater energy under the curve!! Slow rotational load Load Stress strain curves for rapid vs. slow rate of loading
- 22. Rotational ankle fractures are different - good prognosis and few complications with standard techniques
- 23. Dense trabecular structure Thin soft tissues Axial Loading Typical fracture pattern Severe soft tissue injury
- 24. Reudi and Allgower - 1969
- 26. Is this a tibial plafond fracture? Does it belong in 43?
- 27. Plafond yes!! C-2? Or C-3?
- 28. Four principles “stood the test of time” Anatomical reduction Stable internal fixation Atraumatic technique Early pain-free mobilization “Precise reconstruction of articular surfaces is the goal, and is always preferred to tolerable malalignment”.
- 29. These Principals Illustrated for Fractures of the Tibial Plafond
- 30. Ill-Advised Extensive surgical approaches Fracture stripping Prolonged tourniquet times Bulky implants Increased soft tissue injury A recipe for disaster }
- 32. McFerran et al JOT 1992 21pts (40%) with major complications require 77 additional operations Wyrsch et al JBJS 1996 3/18 amputations in closed fractures Teeney and Wiss CORR 1993 37% infection and 26% fusion in Type 3’s Cases Treated 1980’s Early 1990’s
- 33. Delays until surgery Spanning ex fix part of most protocols Percutaneous and limited approaches
- 34. Spanning ex fx Marsh et al JBJS 1995 – 43 cases 0% Wyrsch et al JBJS 1996 – 20 cases 5 % External fixation same side Court Brown et al JOT 1999 – 24 cases 4% Tornetta et al JOT 1993– 26 cases 7% Delayed plating 0-10% Patterson and Cole JOT 2001 – 22 cases 0% Sands et al CORR 1998– 64 cases 6 % Sirkin et al JOT 1999 - 48 cases 6%
- 35. 1. Spanning articulated fixation with percutaneous or limited approaches to the articular surface and screw fixation 2. Percutaneous plating 3. Standard plating through open approaches after long delays for soft tissue recovery
- 36. Spanning fixator for three months A large monolateral frame fixed into the talus and calcaneus Relatively earlier approaches to reduce the articular surface percutaneously
- 37. Suited for all tibial plafond fractures Ideal for very comminuted cases Contraindicated with ipsilateral talus or calcaneus fractures Beware diaphyseal extension or severe open fractures which might delay healing
- 38. Articulated Advantages Span the zone of injury Fixator applied first Same technique all cases One step surgery Largely percutaneous
- 39. Target the neck of the talus posterior os calcis FIXATOR TECHNIQUE - Same for all cases!
- 40. Technical tips Talar pin parallel to top of talus
- 41. Depth of insertion – Hindfoot pins must capture the entire talus and calcaneus Canale view Harris view
- 42. Technical tips Position of pins Assembled fixator Keep the pins in the same plane!
- 43. Center the talus on two views The articular surface can not be reduced if the talus Is not repositioned
- 44. Axial CT scan critical for pre op planning The more you use limited approaches the more planning that is required
- 45. Limited or percutaneous approaches and use of reduction aids
- 46. Reduction forceps based on anterolateral incision – Watch out for SPN!
- 47. Open approaches when necessary based on major anterior fracture line Direct approaches - no stripping
- 48. Percutaneous reduction sequence visualized flouroscopically
- 51. 2 year follow up
- 52. Never plated Treat with fixator Bone graft less than 10%
- 53. ROM Splinting Wt. Bearing
- 54. ~ 3 months after injury Outpatient clinic Calcaneal screw typically loose Often use SLC for another month
- 55. Uses medial sub cutaneous border Needs pre contoured plate Locking may offer advantages Ideal for a select group of fractures Non articular distal tibia Limited articular involvement Build back articular block through limited approaches
- 56. Distal ttiibbiiaa wwiitthhoouutt aarrttiiccuullaarr iinnvvoollvveemmeenntt
- 57. Reduction: Ligamentotaxis External fixator Femoral distractor Manual traction Well placed clamps
- 59. If Injured, Repair the Fibula
- 60. Pre-size and bend plate Or use precountoured plate
- 61. Anatomy: Medial face • Rotation • Curve
- 62. Incision
- 63. SubQ Tunnel
- 64. Insert plate
- 66. Stab……Drill, Tap, Screw
- 67. Post-op
- 68. 4 months
- 72. AAnnootthheerr eexxaammppllee iinn aa mmoorree ccoommpplleexx ffrraaccttuurree
- 74. 5 months
- 75. Indicated to treat the range of tibial plafond fractures Temporary spanning fixation and long delay to definitive surgery Several different open approaches
- 76. 1st Stage: Temporary Fixation application of spanning external fixator, ORIF of the fibula, as soon after presentation as possible, stabilize the fracture while allowing the soft tissue swelling to resolve, Interim: ice, elevation, pre-operative plan, TIME to allow swelling to resolve, 2nd Stage: Definitive Fixation ORIF tibia, removal of external fixator,
- 77. “Traveling Traction” Half Pins Transfixation Pin
- 78. Ice, elevation, CT scan, crutch training, Pre-operative plan, TIME to allow swelling to resolve,
- 79. Fibula posterolateral approach when an anteromedial approach to the tibia is planned, maximize the width of the skin bridge,
- 80. Fibula Implants: Metaphyseal fracture 1/3 tubular plate, large screw,
- 81. Fibula Implants: Metaphyseal fracture 1/3 tubular plate, large screw,
- 82. Fibula Implants: diaphyseal fracture 3.5 LC – DCPlate Rationale: cortical bone, highest energy fractures, slower healing,
- 83. Extensile Anteromedial Approach: “Workhorse”, Anterolateral Approach: gaining in popularity, Posterolateral Approach: recently proposed,
- 84. Anteromedial Approach Superficially: minimum 7 cm skin bridge, begin ½ finger breath lateral to crest over the anterior compartment, continue parallel to Anterior Tibialis tendon, towards the talonavicular joint, Post-operative soft tissue complications
- 85. Anteromedial Approach Superficially: begin ½ finger breath lateral to crest over the anterior compartment, continue parallel to Anterior Tibialis tendon, towards the talonavicular joint, maintaining a 7 cm skin bridge, Medial talonavicular joint medial
- 86. Anteromedial Approach Deep dissection: carried out medial to Anterior Tibialis tendon, longitudinal arthrotomy, gentle elevation of tendons and neurovascular bundle, medial
- 88. Anteromedial Approach Deep dissection: remain medial to Anterior Tibialis tendon, longitudinal arthrotomy, gentle elevation of tendons and neurovascular bundle, medial
- 89. Articular Reduction: largest and least displaced articular fragments first, reduced fragments held with: K-wires (1.2 or 1.6mm), pointed reduction forceps, lag screws, reduce articular bloc to shaft, definitive fixation,
- 90. DON’T make medial a incision !!! the incision ends up directly over the plate, difficult to close, increased wound complications, deep infection, soft tissue loss, free flap only bailout, burn bridges later reconstruction, Not This Incision !!
- 91. Make This Incision !!
- 92. Anterolateral Approach Indications: open medial wound, displaced Chaput fragment, lateral articular comminution, Advantage: plate coverage, uninjured skin, Caution Superficial peroneal nerve
- 93. Anterolateral Approach Deep Dissection: through superior and inferior retinaculae, interval between toe extensors and fibula, elevate muscles off interosseous membrane, Caution Superficial peroneal nerve
- 94. Anterolateral Approach Deep Dissection: through superior and inferior retinaculae, interval between toe extensors and fibula, elevate muscles off interosseous membrane, Caution Superficial peroneal nerve
- 95. Posterolateral Approach Advantages a single incision for ORIF of the tibia and fibula, FHL is positioned between the skin and the implants in case of post-op wound complication, Disadvantages limited access to anterior articular fracture fragments, prone position, sural nerve at risk,
- 96. Implants: Small Fragment Plates cloverleaf shaped plate, distal radius “T” plates, 1/3 tubular plates, 3.5 LC-DCP, Screws 3.5 cortical/4.0 cancellous, cannulated: 4.0/4.5
- 97. Implants: Small Fragment Plates cloverleaf shaped plate, distal radius “T” plates, 1/3 tubular plates, 3.5 LC-DCP, Screws 3.5 cortical/4.0 cancellous, cannulated: 4.0/4.5
- 98. Bone Graft support articular fragments, augment healing, fill cancellous defects, ICBG, Allograft, Synthetic Calcium putties,
- 99. Meticulous Wound Closure meticulous closure, 1-0 vicryl for capsule, 2-0 vicryl for subcutaneous tissue, 3-0 nylon for skin, Allgower’s modification of the Donati stitch, Allgöwer stitch modified by ADllognöawtier stitch modified by Donati
- 100. Summary: Tibial Plafond Fractures Represent both a bony and soft tissue injury, AO Principles: Anatomic articular reduction, stable fixation, early mobilization of patient and limb. several approaches to the tibia can be safely used, internal fixation is accomplished with small fragment implants, meticulous soft tissue closure,
- 101. Results
- 102. Most have some pain Most return to work Detectable arthrosis - 50% Arthrodesis rare
- 103. Pain Analysis 50% - no/minimal pain 35% - pain with weight bearing 15% - continuous Marsh et al. JBJS 1995
- 104. Sands et al CORR 1998 - 2-4 years after injury Delayed plating Pollak et al JBJS 2003 – average 3.2 years after injury Plating and external fixation Marsh et al JBJS Feb 2003 – 5-11 years after injury Spanning external fixation
- 105. SF-36: Plafond vs Aged Matched Norms 5-11 years after injury (Marsh et al JBJS Feb 100 80 60 40 20 0 PF* PR* BP* GH VT SF RE MH Plafond Norm 03) Significantly different
- 106. Ankle Osteoarthritis Scale: Plafond 5-11 Years after Injury 1.2 1 0.8 0.6 0.4 0.2 0 Pain Disability Mean Plafond Norm
- 107. 20 18 16 14 12 10 8 6 4 2 0 Grade 0 Grade 1 Grade 2 Grade 3 # of patients
- 108. 25/33 rated their ankle good or excellent Motion avg. 75% opposite Only 2/37 late arthrodesis 5.4%
- 109. Reasonable evidence that patients improve for a long time! Do not be too quick to offer reconstruction! Sequential Ankle Score: 67 at 24 mo, 86 at 92 mo (p.004) Time to maximal healing: 2.4 yr (9 mo-5 yr)
- 110. 1986 - 24 yo Male
- 111. 1 year
- 112. 7 years
- 113. 14 years Works light labor Prefers high top boots Occasional pain Ankle score 80
- 114. Excellent results are only rarely achieved Most have some ankle pain Can not run or play sports Measurable effect on general health status 70% with moderate or severe arthrosis
- 115. Fair to Good Results Are the Norm Most rate their outcome as good or excellent Arthrodesis rate only ~ 5% Most feel they improve for years
- 117. High energy fractures with severe associated soft tissue injury Unpredictable outcomes Keep complications – 10% or less Results: Generally not great But if you stay out of trouble not awful
- 118. Long lasting effect on patient health related quality of life and a greater effect on ankle pain and function Arthrosis common by 2 years after injury and typical in the second five years. The clinical significance is variable. The variation in outcome is unpredictable The severity of injury/quality of reduction are important but better techniques to understand this critical interaction are needed
- 119. Do not be quick to suggest arthrodesis based on severity of injury or quality of reduction Patients improve for a long time and most do not require arthrodesis Complications must be avoided since they produce bad outcomes and the extent that we improve outcome with aggressive surgery is at least unclear