Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator

Tibial plafond or pilon fractures account for 5 to 10% of all lower extremity fractures and are associated with high energy trauma. They are the result of predominantly axial loading resulting in a typical three fragment and comminuted pattern.¹ These fractures have a high rate of non-union, mal-union, and wound healing issues due to weak metaphyseal bone, a lack of robust soft tissue coverage, and complex intra-articular extension.

Early studies demonstrating higher rates of complications after acute management have promoted a strategy of “staged” management.^2,3 In this approach, the initial injury is initially stabilized with the use of temporary external fixation and definitive fixation is delayed until soft tissues are amenable to primary closure of incisions. While staged management has been considered the standard of practice, more recent work has reported good outcomes with acute definitive fixation in well selected patients.^4,5

In this manuscript and video, we demonstrate a tibial pilon fracture managed acutely with a hybrid fixation approach combining internal fixation with external fixation.

A focused history should include the patient’s age, past medical history, and functional status and should elucidate the mechanism of injury. The primary concern in acute management of tibial pilon fractures—especially when considering acute internal fixation—is the integrity of the soft-tissue envelope. The examiner must uncover any medical conditions, medications, or social habits that may compromise the skin or delay would healing. Important examples include diabetes, peripheral vascular disease, use of immunosuppressive medications, long-term corticosteroid use, and active smoking or other nicotine use. High-energy injuries in a young patient suggest a larger zone of soft-tissue injury and will be more likely to lead to significant swelling in the days following injury. Low-energy mechanisms, such as are often seen in geriatric patients, may not cause as much additional damage to the surrounding tissues.

In this case, the patient is a 44-year-old female who sustained a fall going downstairs the day before presentation to our emergency department. Her past medical history is significant for anxiety, depression and active smoking. Her body mass index (BMI) is 25. She initially presented to another institution where she was diagnosed with an Gustillo-Anderson type 1 open left tibia and fibula fracture and received intravenous cefazolin. Her leg was splinted for preliminary immobilization prior to transfer to our intuition. By the time of admission to our institution, 24 hours had elapsed since injury. Laboratory markers obtained were unremarkable, hematocrit and white blood cell count were within normal limits.

In the case of high-energy lower extremity injuries, the entire extremity must be assessed. First, assess for open wounds that can be directly associated or in continuity with the fracture site in the zone of injury. Emergency department management of open injuries should include early irrigation to remove any obvious foreign bodies or gross contamination of the wound. In our institution we perform a saline lavage in the emergency department of all open wounds associated with fractures, then proceed to cover the wound with a gauze soaked in iodine solution. After evaluating for open wounds, the overall state of the rest of the soft tissues should be considered. The amount of swelling should be noted; absence of skin wrinkling suggests significant edema that may compromise would healing. Any fracture blisters should be recognized and covered with a petroleum-impregnated dressing. Displaced fracture fragments may cause skin tension that can impede perfusion and lead to skin breakdown. Skin threatening is indicated by blanched skin overlying a bony fragment and must be recognized. After assessment of the wounds and other overlying skin defects, a complete neuromotor and vascular exam must be performed.

Documentation of the level of sensation, and function of muscular groups along with the presence or absence of pulses and good capillary refill must be performed. When concerns exist for a vascular injury computed tomography (CT) angiography obtained for further definition of the vascular injury after stabilization of the fracture.

Our patient’s overall physical exam of the left lower extremity was significant for obvious deformity with a small wound (< 1 cm) on the medial side of ankle. The soft tissue was otherwise well maintained. There was minimal swelling of the leg with no fracture blisters. No further areas of skin threatening were noted. The leg was soft and all compartments were compressible. The patient was tender to palpation over the ankle but had a painless passive range of motion of the knee and toes. She was able to activate the anterior tibialis, extensor hallucis longus, and flexor hallucis longus muscles. Sensation was intact in the distributions of the saphenous, sural, and superficial and deep peroneal nerves. Positive palpable pulses were evident over the dorsal pedis and posterior tibialis arteries. Toes were well perfused.

Radiographs should be obtained upon presentation. Initial radiographs should consist of views of the whole tibia and fibula to determine proximal extent of the injury as well as an ankle series that includes a mortise (15-degree internal rotation) view to assess alignment and comminution at the tibial plafond. CT scan is a crucial and routine component of the preoperative evaluation for most tibial plafond fractures. CT scans have been shown to improve understanding of the number and location of fracture fragments, extent of articular involvement, and location of the major fracture line.⁶  CT assessment frequently leads to changes in the surgical plan compared to use of radiographs alone.⁶ Axial CT images are particularly useful for identifying major fracture fragments and planning placement of surgical incisions.¹ 

Imaging obtained in this case included tib-fib x-rays demonstrating a distal tibia and fibular fracture. The fibular fracture was a simple transverse fracture above the level of the syndesmosis. In the lateral view, shortening and apex posterior angulation of the fracture was noticed. The distal tibia fracture was an oblique fracture at the same level of the fibular fracture. Intra-articular extension was difficult to assess in both antero-posterior (AP) and lateral views. 

A CT scan obtained of the lower extremity demonstrated the typical “Y-shaped pattern” in the axial cuts at the level of the tibial plafond. A very comminuted Volkmann (posterolateral) fragment, an also comminuted Chaput (anterolateral) fragment and a medial malleolar fragment were observed in the axial cuts.

In the coronal view, the tibia was noticed to fall in valgus at the level of the long oblique fracture line in the metaphysis, also in the coronal view there was a small impacted and flipped fragment in the middle of the plafond.

Tibial plafond fractures are treated operatively in nearly all cases due to high rates of malunion with nonoperative treatment.⁷ Initial management may consist of placement of a provisional uniplanar ankle-spanning external fixator if there is concern for the status of the soft tissues, such as significant edema and/or fracture blister formation. If used, external fixation usually remains in place for 7–21 days until swelling has subsided and the skin is amenable to closure of incisions. Conversely, acute definitive internal fixation may be attempted if swelling is minimal. Definitive external fixation, often with a thin-wire frame, may be used in select patients at extremely high risk for wound healing complications. In recent years, some surgeons have advocated for utilizing primary tibiotalocalanceal (TTC) fusion via retrograde intramedullary nailing of the hindfoot as definitive treatment of pilon fractures in some low-demand elderly patients, patients with poorly controlled diabetes, and/or cases with extreme articular comminution. However, hindfoot nailing achieves ankle stability at the expense of loss of both ankle and subtalar joint motion and therefore remains reserved for limited cases.⁸ In the vast majority of cases, definitive surgical management consists of open reduction internal fixation (ORIF) with plate and screw constructs.

ORIF may be accomplished using several surgical approaches. Each approach utilizes a different intramuscular interval to primarily expose a specific aspect of tibia and/or fibula. Often, multiple approaches are combined. The planned incisions and approaches should be tailored to the patient’s unique fracture pattern while considering any wounds around the ankle.¹ The most common approaches used are anterolateral, anteromedial, and posterolateral. In the anterolateral approach, the interval between the anterior compartment tendons and fibula is utilized. An incision is made in line with space between the 3rd and 4th metatarsals, starting distal to the ankle joint, and extended to approximately 5 cm proximal to the joint.^9,10 Care must be taken to avoid injury to the superficial peroneal nerve. The tendons of the anterior compartment are lifted and retracted medially to expose the lateral distal tibia and anterior plafond. The anteromedial approach exploits the space between the tibialis anterior (TA) tendon and the medial malleolus to expose the medial column of the tibia. The incision starts medially just distal to the medial malleolus and curves anteriorly more proximally along the TA. A skin flap can be raised to expose the medial malleolus and medial tibia and the TA and adjacent anterior compartment tendons can be retracted laterally to expose the anterior joint line. In the case of an associated fibula fracture, the anteromedial approach may be combined with a direct lateral approach for fibula fixation.¹⁰ The posterior column of the tibia is most often accessed via a posterolateral interval between the flexor hallucis longus (FHL) and peroneus longus (PL) tendons. This approach is typically performed with the patient prone. The posterolateral incision is made halfway between the Achilles tendon and lateral malleolus. The deep fascia is exposed, taking care to avoid injury to the sural nerve. The fascia is opened and the peroneal tendons retracted laterally. The posterior tibia is exposed by elevating the distal muscle fibers of the FHL. An associated fibula fracture can typically also be accessed and fixated through the posterolateral incision. Many other approaches have been described and are often employed, including direct anterior and posteromedial approaches.

In many cases, multiple surgical approaches may be needed to adequately reduce the fractures and apply fixation. Fixation of an associated fibula fracture is a common reason for using a second incision. The fibula can be accessed via a direct lateral approach that exploits the internervous interval between the extensor digitorum longus (deep peroneal nerve) and peroneus brevis (superficial peroneal nerve). Use of a second incision increases concerns regarding wound healing complications and necrosis of skin bridges. Typically it is thought that incisions must be separated by at least 7 cm. However, careful soft-tissue handling and closure of incisions using perfusion-preserving suture techniques can allow for smaller skin bridges. A prospective study of 46 pilon fractures found low risk of wound-healing complications with skin bridges that were on average 5.9 cm and with 83% being <7 cm when excessive soft tissue dissection and over-vigorous retraction were avoided and wounds were sutured using the Allgower-Donati technique.¹¹ To reduce the risk of wound healing complications with multiple incisions, the location of all necessary incisions should be carefully planned preoperatively.

Once the fractured tibia is exposed, cortical fragments can be booked open to expose the impacted articular fragments. Individual fragments are manipulated and reduced using the intact talar dome as a template. Provisional reduction may be held with a combination of Kirchner wires (k-wires) and pointed reduction clamps. Definitive fixation is performed by applying anatomically contoured small fragment locking plates in positions that resist valgus or valgus collapse, depending on the fracture pattern. Independent 3.5-millimeter (mm) or 2.7-mm screws may be used between fragments to rebuild the articular surface.^{11,121314–17}

The goals of treatment for tibial plafond fractures are anatomic reduction of the articular fragments to recreate a congruent articular surface, preservation of articular cartilage, and restoration of anatomic relationships and mechanical alignment of the leg and ankle joint.

Given the presence of an open fracture, surgery was indicated for this patient in an urgent fashion. The procedure began with wound exploration and irrigation and debridement to address the open fracture. An anteromedial incision was then selected as the primary approach taking two factors into consideration: 1) The CT scan suggested the fracture pattern could be fixed through this approach while also allowing access to the anteromedial corner of the ankle joint to visualize the joint for proper anatomic reduction, and 2) The open wound could be incorporated into the planned incision. Because skin swelling was minimal and an incision was already required for irrigation and debridement of the open fracture, we proceeded with acute ORIF. An external fixator was used for provisional stabilization intraoperatively and was left in place at the end of the case.

The use of an anteromedial approach was helpful to address the axial failure of the tibia with compression laterally, thus, the anteromedial approach would allow us to address this coronal deformity. Through this approach we were able to reduce both the Chaput and Volkmann’s fragment with k-wires and eventually fixation with the plate. The use of a second incision to address the fibula fracture helped to achieve length and restore alignment of both the tibia and the fibula.

Our patient’s injury resulted in a highly comminuted fracture that required both open reduction and internal fixation plus the additional application of an external fixator for further stability and to protect the underlying fixation and the soft tissues. The decision to apply an external fixator was made intra-operatively and helped to maintain the overall length and alignment of the tibia and fibula. Preoperative CT was useful to understand the fracture pattern and plan for an appropriate surgical approach.¹⁰

Presence of an open wound at the time of initial evaluation should prompt immediate initiation of intravenous antibiotic therapy. Antibiotic choice is determined by the soft tissue compromise of the injury, as determined by the Gustilo-Anderson classification.¹² Many antibiotic protocols have been proposed. Most commonly, type I and type II fractures are treated with a 1st generation cephalosporin (e.g. cefazolin), while type III fractures are additionally given an aminoglycoside (e.g. gentamicin), while penicillin is added for extensive soil contamination. A more recently proposed protocol uses cefazolin for type I and II fractures and ceftriaxone for type III.¹³ To reduce decision-making burden on frontline providers in the emergency department, our institution uses a simplified protocol in which cefazolin is given for type I fractures and piperacillin-tazobactam is given for any fracture type II or higher.

Use of a thigh tourniquet intraoperatively can improve visualization of fracture fragments and reduce intraoperative blood loss. A tourniquet may be especially useful in treatment of pilon fractures as hematoma can obscure the reduction reads for small articular fragments. Tourniquet use comes at the cost of increased intraoperative and postoperative pain and carries small risks of nerve and muscle injury. Safe tourniquet practices should be followed including leaving the tourniquet inflated for no-longer than 2.5 hours consecutively and releasing the tourniquet for 10 minutes of reperfusion at the 2.5 hour mark and every hour thereafter.14

Fractures of the tibial plafond—often referred to as pilon fractures—are complex injures of the distal leg with significant bony and soft-tissue disruption. Historically, nonoperative treatment of tibial plafond fractures was associated with poor reduction of the articular surface, poor maintenance of mechanical alignment of the ankle, and low resulting function. Therefore, in present practice, these fractures are nearly always considered operative injuries.

Surgeons are faced with a multitude of choices when planning operative treatment of tibial plafond fractures. Upon initial presentation of the injury, surgeons must decide for acute definitive fixation versus a staged approach with temporary external fixation. Data regarding acute vs staged management of pilon fractures is conflicting. The main consideration is the risk of wound complications after acute surgical fixation. Tibial pilon fractures are usually high energy injuries that quickly develop acute soft tissue swelling, including blistering. This is largely due to the thin of the ankle skin with little protective subcutaneous tissue. The tibia and fibula are both subcutaneous at the level of the ankle. In these cases, the application of an ankle-spanning external fixator has been a useful temporizing method to protect the traumatized soft tissue envelope, and to allow for safe staged definitive fixation when the soft tissues are improved and can better tolerate surgery (7 or more days later). In some cases external fixation can function as a definitive treatment.^15,16,17 Other studies have demonstrated that acute open reduction and internal fixation (ORIF), when performed appropriately, respecting soft tissue integrity, with a proper incision size and location, can result in similar outcomes with less operative time and overall treatment cost.^18–21 Some studies have demonstrated the efficacy and safety of early fixation, with clear criteria including no excessive soft tissue swelling and the absence of fracture blisters. There are a number of known variables that will increase risk of infection and wound complications regardless of the time of fixation (male gender, smoking and diabetes). Most of the recent studies agree that patients with a good soft tissue envelope, the presence of skin wrinkles, low energy and without significant comorbidities, acute fixation may be reasonable and safe.^19,20

Presence of an open fracture demands a surgical incision for thorough irrigation and debridement. In such a case, surgeons may be more likely to opt for at least partial internal fixation in an acute fashion. Once deciding to move forward with definitive internal fixation, the surgeon must select the surgical approach(es) that will safely provide access to the crucial fracture fragments to be able to both reconstruct the tibial plafond and restore and maintain length and mechanical alignment of the tibia. Multiple surgical approaches have been described utilizing anterior, posterior, and lateral intramuscular intervals, each of which provides access to a specific region of the tibia.

In the case described in this video, an incision was required for irrigation and debridement of an open fracture. The traumatic wound was in the path of an incision for an anteromedial approach, which was utilized. Because this incision was being made and skin swelling remained minimal over 24 hours after injury, the soft tissue envelope was deemed appropriate and safe for acute surgical fixation and we elected to proceed with acute definitive ORIF. We performed a hybrid approach with both acute fixation complemented with external fixation. First, a transcalcaneal pin was placed to be able to pull traction and assist in the reduction of both the fibula and tibia for plating, allowing for restoration of anatomical length. A six-hole 1/3 non locking, semi tubular, 3.5-mm plate was applied to the fibula after reduction was achieved. K-wires were used for temporary stability.

After fixation of the fibula, an ankle spanning external fixator was constructed by adding Shantz pins to the tibia and connecting the appropriate clamps and bars. Anatomic alignment of the tibia that restored medial column length was then achieved using manipulation of the external fixator under fluoroscopic imaging and the frame was tightened. Then, an anatomically-contoured medial distal tibia 3.5-mm non-locking plate was applied spanning the area of comminution. Additional fixation was achieved with 3.5-mm screws perpendicular to the anterior to posterior fracture plane. Along with the application of the plate, the underlying bone void was filled with bone graft consisting of cancellous allograft chips. Wounds were then profusely irrigated with saline solutions and closed primarily with application of 1 gram of vancomycin powder during wound closure. While the external fixator is often removed following ORIF of tibial pilon fractures, in this case we elected to maintain it postoperatively. This was done for multiple reasons. First, given the comminution of the tibial cortex, the ex-fix provided increased stability during the early healing stages to guard against failure into valgus. Second, the patient had increased risk of wound healing complications given the open fracture and active smoking; maintaining the external fixator allowed for stability for soft tissue rest while leaving the incisions accessible for monitoring, which would not have been possible in a postoperative short-leg splint.

The patient was discharged home on postoperative day 4 after ambulating safely and independently with an assistive device and achieving proper pain management. The patient was made non weight bearing (NWB) on the operated limb and the external fixation device precluded any range of motion at the level of the ankle. First follow up was at 15 days post-op, and at that time the patient demonstrated a well-healed incision, and all hardware was intact on radiographic assessment. She was asked to remain NWB on the left lower extremity. At postoperative week 4, the patient was taken back to the operating room for external fixator removal and examination. Examination revealed a stable fixation construct without signs of hardware failure or other radiographic concerns.

• Large external fixator.
• Kirschner wires of various sizes.
• Weber reduction clamps of various sizes.
• Anatomically contoured distal tibial plates.
• Small fragment locking and non-locking plates.
• Small fragment locking and non-locking screws.