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The Journal of Bone and Joint Surgery 78:1772-83 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

Instructional Course Lecture

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Fractures of the Ankle and the Distal Part of the Tibia*{dagger}

ROBERT VANDER GRIEND, M.D.{ddagger}, GAINESVILLE, FLORIDA, JAMES D. MICHELSON, M.D.§, BALTIMORE, MARYLAND and LARRY B. BONE, M.D.¶, BUFFALO, NEW YORK

An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons


   Introduction
Top
 Introduction
Ankle Fractures
 Pilon Fractures
 Overview
 References
 


   Ankle Fractures
Top
 Introduction
 Ankle Fractures
Pilon Fractures
 Overview
 References
 
Ankle fractures are the most common types of fractures treated by orthopaedic surgeons7,44. There has been an increased prevalence of such fractures over the last two decades both in young, active patients and in the elderly7,44. There also seems to have been an increased prevalence of complex injuries of the ankle and foot as a result of the increased use of automobile safety devices, such as seat belts and air bags, which decrease mortality and protect the trunk but not necessarily the lower extremities.

As a result of a better understanding of the biomechanics of the ankle, improvements in fixation techniques, and findings of outcome studies, there has been a gradual evolution in the effective strategies for the treatment of ankle fractures. The goals of treatment continue to be both a healed fracture and an ankle that moves and functions normally without pain. The development of strategies for the treatment of various patterns of ankle injuries revolves around whether these goals can be achieved more predictably with operative or non-operative means.

Operative treatment is indicated when congruity of the joint cannot be restored with closed methods. With intra-articular fractures of the distal part of the tibia, such as pilon fractures, there often is major incongruity of the weight-bearing articular surface that must be corrected. With ankle fractures, the primary concern is residual instability of the joint as malalignment or residual displacement can adversely affect the biomechanical behavior of the ankle and result in loss of function. Certain injury patterns have a better outcome after operative treatment, while other patterns are better treated non-operatively.

The treatment of ankle fractures involves both a risk-benefit and a cost-benefit analysis. The primary risk associated with closed treatment is inadequate restoration of the biomechanics of the ankle, which can lead to a poor outcome. Conversely, while open reduction and internal fixation is an excellent method for the restoration of the normal anatomy of the joint, it is accompanied by the costs and risks of an operation.

Anatomy and Biomechanics
An understanding of the anatomy and biomechanics of the ankle is essential before one can evaluate and treat injuries involving that joint. The ankle consists of the articulating surfaces of the talus, tibia, and fibula as well as their interconnecting ligaments and the joint capsule. The ankle often is divided into medial, lateral, and syndesmotic complexes to help the physician to understand the mechanism of injury better and to devise a treatment plan. The medial complex consists of the medial malleolus, the medial facet of the talus, and the superficial and deep components of the deltoid ligament; the lateral complex consists of the distal part of the fibula, the lateral facet of the talus, and the lateral collateral ligaments of the ankle and subtalar joints; and the syndesmotic complex consists of the articulation between the tibia and the fibula as well as the interconnecting ligaments of the syndesmosis and the interosseous membrane.

While the ankle previously was considered to be a simple hinge joint, many studies have shown clearly that the biomechanics of the ankle are quite complex32,36,37,47. The contributions of the articular surfaces, the ligaments, and the capsular and musculotendinous structures to the stability and function of the ankle are influenced by changes in loading characteristics and joint position and are altered in response to injury. These biomechanical studies have shown that as the ankle moves in the sagittal plane the talus both slides and rotates underneath the tibial plafond32,35,36. In addition, motion of the ankle in the sagittal plane induces coupled motions in both the coronal and the axial plane. Plantar flexion of the ankle results in internal rotation of the talus, while dorsiflexion results in external rotation32,47,57 (Fig. 1). Dorsiflexion also results in posterolateral translation and external rotation, but in minimum vertical motion, of the fibula17,31,48.



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  		Illustration of the coupled motion that occurs when the ankle is moved into dorsiflexion and plantar flexion. The talus rotates externally when the ankle is dorsiflexed and internally when the ankle is plantar flexed.

 
It is now well recognized that the injury patterns associated with ankle fractures are more complex than simple lateral displacement of the talus in the injured mortise. It is difficult to assess displacement, which occurs in multiple planes, with use of two-dimensional radiographs. For example, what appears on plain radiographs to be direct lateral translation of the talus is actually anterolateral rotation of the talus within the mortise20,33,37,64. Failure to appreciate this fact can lead to a misunderstanding of the actual biomechanical changes that occur, can result in the design of inaccurate experimental models, and can contribute to confusion with regard to clinical treatment. Experimental models of ankle fractures that involve only direct lateral translation of the talus do not accurately represent the consequences of the injury.

Historically, the primary goal of operative treatment of ankle fractures was to stabilize the medial side. Later, the lateral side was considered to be more important63. More recent studies35,36,63 have suggested that both sides are important, with the medial side (specifically, the deep component of the deltoid ligament) holding the talus in place and keeping it from displacing laterally and from rotating externally while the lateral side acts as a buttress. The biomechanical consequences of injury must be considered for both sides of the ankle when treatment is being planned.

Radiographic Evaluation
Fractures of the ankle are evaluated primarily with use of plain radiographs. Instability is assessed by means of an analysis of the displacements of various parts of the ankle and the association of these displacements with their perceived biomechanical consequences. The measurements that typically can be obtained are the medial clear space, the tibiofibular clear space, the tibiofibular overlap, the talar tilt, and the talocrural angle (Fig. 2).



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  		Illustration of the measurements, made on plain radiographs, that are used to determine the displacement associated with an ankle fracture. The width of the syndesmosis is measured one centimeter proximal to the tibial plafond. (Modified from: Vander Griend, R. A.; Savoie, F. H.; and Hughes, J. L.: Fractures of the ankle. In Fractures in Adults, edited by C. A. Rockwood, Jr., D. P. Green, and R. W. Bucholz. Ed. 3, vol. 2, pp. 2003, 2005. Philadelphia, J. B. Lippincott, 1991.)

 
The utility of a radiographic examination of an ankle fracture is limited, as all of the measurements are subject to interobserver variability. In addition, the measurements vary depending on whether the radiographs are made during weight-bearing or non-weight-bearing, and the degree of magnification is uncalibrated and varies from patient to patient. Finally, there are differences in the literature with regard to what is normal, abnormal, or acceptable, and there is a limited understanding of the biomechanical consequences of small amounts of displacement6,18,55,60,63. Re-evaluation of these measurements with newer techniques, such as computed tomography, also has called into question the validity of some previously accepted concepts. For example, fibular length commonly has been estimated with use of the talocrural angle. Although it has been stated that a change in the talocrural angle of as little as 2 degrees compared with the angle on the normal side reflects fibular shortening, examinations of fractures with use of three-dimensional computed tomographic scans have not supported this contention18,38,49,55.

Classification
The treatment of ankle fractures is based almost entirely on the radiographic findings. Currently, there are two widely used classification systems.

Lauge-Hansen apparently devised the first modern classification system that was based specifically on the mechanism of injury29. This is a two-part system in which the first word of the classification denotes the position of the foot at the time of the injury and the second word indicates the direction of the deforming force. The initial position of the foot is important because it determines which structures are tight and therefore are most likely to be injured first. (For example, with the foot supinated, the medial structures are loose and the lateral structures are tight; the lateral structures, therefore, are injured first.) The severity of the injury then is defined as stage 1, 2, 3, or 4, depending on the particular pattern. The two most common injury patterns are the supination-external rotation and pronation-external rotation types. The supination-external rotation injury begins at the anterolateral corner of the ankle. The structures that are damaged are, in order, the anterior tibiofibular ligament (stage 1), the lateral malleolus (stage 2), the posterolateral aspect of the capsule or the posterior malleolus (stage 3), and the medial malleolus or the deltoid ligament (stage 4). The pronation-external rotation injury begins on the medial side of the ankle with an injury of the deltoid ligament or the medial malleolus (stage 1) and then progresses around the ankle to the anterolateral ligaments (stage 2), the lateral malleolus or the proximal part of the fibula (stage 3), and the posterolateral ligaments or the posterior malleolus (stage 4). Other, less common injury patterns include the supination-adduction and pronation-abduction types.

As the Lauge-Hansen classification system is based on the mechanism of injury, its primary advantage in the past was that it could be used as a guide for the closed reduction of ankle injuries. Although this system remains useful for describing the mechanism of injury, it is complicated and, regardless of the experience of those interpreting the radiographs, its clinical usefulness is limited by variable interobserver reliability42,52.

The Weber classification system is based on the level of the fibular fracture: type-A fractures occur distal to the level of the tibial plafond, type-B fractures start at the level of the plafond and frequently spiral proximally, and type-C fractures originate proximal to the level of the plafond and are associated with a variable amount of syndesmotic injury40. While this system is easy to use and provides information about the lateral fracture, it does not discriminate adequately between fractures that are quite distinct biomechanically30. For example, with use of this system, fibular fractures with a medial injury are indistinguishable from those without such an injury.

The AO classification system is a modification of the Weber system in which the A, B, and C fracture types are subdivided on the basis of the presence of medial or posterior injury39. Familiarity with both the Lauge-Hansen and the AO-Weber system enables the surgeon to appreciate the mechanism of injury and yet still use the simpler, and now more comprehensive, AO system.

Current Issues in the Treatment of Ankle Fractures
Although the evolution of internal fixation techniques has settled much of the controversy regarding the treatment of ankle fractures, some aspects of treatment remain subject to debate.

As noted earlier, there have been several recent studies of the biomechanics of ankle motion. Of particular importance has been the recognition that instability of the ankle results from external rotation of the talus20,33,37,64. The medial structures provide the primary restraint to this pattern of instability, while the lateral structures contribute relatively little to stability16,37. As this concept has become more widely recognized, operative indications based strictly on the characteristics of the lateral injury pattern have been called into question. In previous reports, the amount of acceptable fibular displacement has ranged from zero to as much as five millimeters7,8,18,26,49. This wide range supports the notion that apparent fibular displacement does not provide a satisfactory indication of ankle instability and does not define treatment requirements.

Isolated Lateral Malleolar Fractures
Isolated fractures of the lateral malleolus are the most common fractures of the ankle. By definition, this type of fracture is associated with no appreciable medial injury of either the deltoid ligament or the medial malleolus.

In recent years, there has been a trend toward treating this type of fracture with anatomical open reduction and internal fixation. This approach has been based, in part, on the finding that displacement of the talus follows displacement of the lateral malleolus64 and on the experimental work of Ramsey and Hamilton51, who found that one millimeter of lateral talar shift reduces the ankle contact area by 42 per cent. However, in that study51, the lateral talar shift was achieved by placing shims between the talus and the medial malleolus and loading the ankle in the neutral position only. That study reflected the then-current thought that a fracture causes the talus to shift laterally rather than to rotate anterolaterally, as is actually the case. In that study, ankle motion was constrained by the testing apparatus. Subsequent studies have shown that it is important for the models used for biomechanical testing to account for the normal complex coupled motions of the ankle14,36,37.

A number of recent studies have re-examined the biomechanics of lateral malleolar fractures. These studies have included measurements of the contact area through a full range of motion16, measurements of intra-articular pressure with use of a quasidynamic methodology13, and direct measurements of three-dimensional motion of the ankle36,37. None of these laboratory investigations demonstrated any change in the loading characteristics or the motion of the ankle as a result of an isolated lateral malleolar fracture.

Computed tomographic studies have indicated that the amount of displacement of the distal fibular fragment with respect to the proximal portion of the fibular shaft is overestimated on plain radiographs38. The classic description of a lateral malleolar fracture is that of a fracture in which the distal fibular fragment is externally rotated; however, computed tomographic scans showed that such external rotation rarely occurs38. The typical deformity actually is characterized by internal rotation of the proximal portion of the fibular shaft relative to the tibia and no substantial rotation of the distal part of the fibula with respect to either the tibia or the talus. This internal rotation of the proximal portion of the fibular shaft most likely is a result of the muscular and syndesmotic attachments to that part of the bone. The talofibular articulation remains unchanged because of the preservation of the ligamentous and articular constraints. On the basis of these findings, it would be expected that the results of non-operative treatment of isolated lateral malleolar fractures would be as good as those of operative treatment. This was, in fact, demonstrated in two studies6,28, in which seventy-five of eighty-two patients had a good clinical result—despite as much as three millimeters of apparent fibular displacement—at least twenty years after the closed treatment of a stage-2 supination-external rotation fracture. Furthermore, in three other studies, the outcome after anatomical open reduction and internal fixation was not found to be substantially different than that after non-operative treatment8,62,66. The findings of these studies6,8,28,62,66 suggest that as much as three millimeters of residual displacement is well tolerated after an isolated fracture of the lateral malleolus.

Deltoid Ligament Injuries
A lateral malleolar fracture that is associated with a complete injury of the deltoid ligament is biomechanically equivalent to a bimalleolar fracture9,13,35. The diagnosis of a complete rupture of the deltoid ligament is based on the presence of medial tenderness as well as evidence of a talar shift as determined by more than four millimeters of widening of the medial clear space as seen on the post-injury radiographs18,21. The clinical situation is not as clear when there is medial tenderness without any discernible talar shift. Stress radiographs may be considered and close radiographic follow-up is necessary, especially when non-operative treatment is selected.

A fibular fracture with associated disruption of the deltoid ligament should be treated with operative stabilization of the fibula. Unless an interposed deltoid ligament or other soft tissue blocks reduction of the talus, a medial arthrotomy and repair of the deep component of the deltoid ligament is not necessary to achieve a good outcome5,18,64. Postoperatively, the ankle should be immobilized in slight dorsiflexion for about three weeks. This minimizes the rotational forces on the talus that accompany normal dorsiflexion and plantar flexion of the ankle. Although some authors5,21 have described the use of an above-the-knee cast, we have not found this to be necessary60,63.

Posterior Malleolar Fractures
A fracture of the posterior malleolus can occur in association with either external-rotation or abduction injuries of the ankle. The mechanism of injury is usually an avulsion force acting through the posterior syndesmotic ligaments on the posterolateral part of the tibia. Less commonly, the mechanism is impaction of the externally rotating talus on the posterior lip of the tibia. The primary issues regarding the treatment of a posterior malleolar fracture have been the effect of the size of the fragment on posterior stability of the ankle and what criteria should be used to determine when internal fixation is needed. Harper, in an experimental study, showed that posterior malleolar fractures involving as much as 50 per cent of the articular margin (as seen on the lateral radiograph) were not associated with posterior talar subluxation, provided that the lateral supporting structures were intact22. Harper and Hardin, in a clinical study, reported similar results when posterior malleolar fractures involving approximately 25 per cent of the articular surface were treated with and without internal fixation, provided that the lateral and, if present, the medial fractures were anatomically reduced and stabilized23.

Clinically, the posterior malleolar fragment often reduces with reduction of the fibula. Most current texts recommend internal fixation of the posterior malleolus if the reduced fragment comprises more than one-fourth to one-third of the articular surface60,63. An additional indication for open (or percutaneous) reduction and fixation is persistent intra-articular displacement of the posterior malleolar fragment after reduction of the lateral and, if present, the medial malleolar fractures. A step-off or gap of more than two to three millimeters should be reduced and fixed, especially if there is associated posterior subluxation of the talus. Residual posterior subluxation of the talus should not be accepted as it will lead to rapid destruction of the ankle joint. Fixation can be achieved with use of screws placed either posterior-to-anterior or anterior-to-posterior, depending on the size of the posterior fragment63. All of the fractures (those involving the medial malleolus, the lateral malleolus, the posterior malleolus, or any combination of the three) should be either reducible or reduced and provisionally stabilized with Kirschner wires or a malleolar clamp before definitive fixation is accomplished.

Syndesmotic Injuries
There continues to be some controversy regarding the evaluation and treatment of syndesmotic injuries. The primary issues include determination of when the injured syndesmosis is unstable, when and what type of syndesmotic fixation is needed, and how the patient should be managed postoperatively.

Injuries of the syndesmotic ligaments occur as a result of abduction or external rotation of the talus within the ankle mortise. This mechanism most commonly occurs in association with pronation-external rotation, pronation-abduction, and occasionally supination-external rotation injuries29 (type-C and some type-B injuries40).

In abduction injuries, the medial side is injured first and then the syndesmotic ligaments are torn or avulsed along with their osseous attachments. The proximal extent of the injury of the interosseous membrane and the level of the fibular fracture depend on the loading forces. In external-rotation injuries, the anterior syndesmosis is disrupted. The interosseous membrane and the posterior tibiofibular ligament may or may not remain intact as the fibula rotates externally and subsequently fractures.

Stability of the ankle results from contributions of the medial complex (the medial malleolus and the deltoid ligament), the lateral complex (the lateral malleolus and the lateral ligament complex), and the syndesmotic complex. Usually, at least two of these complexes must be injured for the ankle to become unstable. Burns et al., in an in vitro biomechanical study, showed that the loading characteristics of the ankle did not change substantially when only the syndesmotic ligaments were cut; however, when both the syndesmotic and the medial ligaments were cut, there was an increase in both talar shift and joint-contact pressure as well as a 39 per cent decrease in joint-contact area13.

In another study9, the relationship between medial injury and the level of syndesmotic injury was studied. When there was no medial injury (that is, when the deep component of the deltoid ligament and the medial malleolus were intact), there was minimum widening of the syndesmosis, regardless of the proximal extent of the syndesmotic injury. When a medial injury was combined with a disruption of the syndesmosis that extended more than 4.5 centimeters proximal to the joint, there was widening of the syndesmosis and changes in the loading characteristics of the ankle. No changes in the loading characteristics were seen when the syndesmosis was disrupted for a distance of less than 3.0 centimeters proximal to the joint.

In the past, fixation of the syndesmosis was recommended routinely for patients who had a fracture of the fibula proximal to the level of the ankle joint. More recent reports have suggested that the need for trans-syndesmotic fixation may be less than was previously assumed63. Recent biomechanical testing and clinical outcome studies4,9,35,45,46,65 have led to a number of conclusions:

1. If the medial and lateral complexes are intact or can be restored anatomically and stabilized with internal fixation, the syndesmosis usually will be stable regardless of the degree of injury.

2. If the syndesmotic injury occurs as an osseous avulsion of the ligament or ligaments, reduction of these osseous fragments with or without fixation usually restores stability to the syndesmosis, especially if the medial and lateral complexes also are anatomically restored.

3. Internal fixation of the syndesmosis may be needed if there is a fracture of the fibula that extends more than three to four centimeters proximal to the joint line as well as an associated medial-side injury that cannot be fixed or repaired (even if the fibular fracture has been fixed anatomically).

4. Internal fixation of the syndesmosis may be needed if there is a fibular fracture proximal to the level of the ankle joint for which fixation is not planned and there also is a medial-side injury that cannot be fixed in a stable position.

Instability of the syndesmosis is identified primarily on the basis of the mechanism of injury and the fracture pattern. Clinical tests such as the squeeze test (manual medial-lateral compression across the syndesmosis) and the external-rotation stress test can elicit pain, but the findings may not be reliable in the acute setting. Radiographic parameters are helpful. A tibiofibular clear space (Fig. 2) of less than five millimeters and widening of the medial clear space of more than four millimeters are strong indications of a syndesmotic injury. Intraoperatively, the fibula can be manipulated to determine if there is excessive lateral displacement indicative of a syndesmotic injury. This is accomplished with use of the hook test, in which the fibula is grasped with bone forceps or a bone hook and is pulled laterally. While this test may demonstrate gross instability, this finding usually is already apparent on the preoperative radiographs. The sensitivity of this test for subtle instability is not known.

An external-rotation or abduction stress radiograph should be made when there is any remaining uncertainty with regard to the stability of the syndesmosis. The medial clear space normally widens by two to three millimeters with external-rotation or abduction stress. Widening of more than four millimeters indicates an injury of the syndesmotic and deltoid ligaments.

Apparent widening of the medial clear space may be observed if radiographs are made with the ankle in plantar flexion, especially if there is associated medial capsular or ligamentous injury. The reason for this apparent widening is that, with the ankle in plantar flexion, the narrowest part of the talus is within the mortise. With associated medial ligamentous injury, the talus can rotate externally, especially with plantar flexion and an anterior drawer effect from pressure on the posterior aspect of the heel; this situation also contributes to the appearance of medial widening. Radiographs made with the ankle in neutral prevent this misinterpretation.

If the syndesmosis is unstable, trans-syndesmotic fixation is recommended. Anatomical reduction of the syndesmosis is necessary, and the talus must be reduced in the mortise. If the fibula is fractured, its length, rotation, and alignment are restored first, and then the bone is reduced in the tibial notch. If the medial malleolus is fractured, it should be reduced and fixed as well. The reduction of the tibiofibular joint must be maintained during placement of any type of trans-syndesmotic fixation. Although many methods of fixation, including suture and use of synthetic grafts, have been reported63, fixation with screws is the most common technique.

The fixation screw is a positioning screw; its function is to hold the syndesmosis in the reduced position. The screw can be used independently or in conjunction with a plate, depending on the type and location of the fibular injury. The screw is inserted at the top of the fibular sulcus in the tibia, usually about three to four centimeters proximal and parallel to the ankle joint, and is angled approximately 30 degrees anteriorly so that it is perpendicular to the tibiofibular joint and will not miss the tibia. Screws that are placed too far proximally may deform the fibula and widen the mortise. Screws that are not parallel to the ankle joint or not perpendicular to the tibiofibular joint can cause the fibula to shift proximally or laterally.

If the fibular fracture is proximal, as in a Maisonneuve injury, and fixation of the fibula is not planned, accurate reduction of the fibula is essential. Determination of when the fibula is reduced can be difficult, especially if the fracture is comminuted. Guides to reduction include realignment of the articular surface of the fibula with the lateral facet of the talus, intraoperative measurement of the talocrural angle, and comparison with radiographs of the contralateral ankle. Alignment of the trans-syndesmotic screw is particularly important, as a misplaced screw can cause the fibula to shift and then can hold it in a malreduced position. In some situations (for example, when the patient is large or when compliance with non-weight-bearing is in doubt), two syndesmotic screws may be used.

It has been recommended that fixation of the syndesmosis be performed with the ankle in full dorsiflexion to avoid overtightening of the mortise and loss of dorsiflexion postoperatively. However, in this fully dorsiflexed configuration, the mortise is in its widest position and the fibula is shifted laterally and rotated externally. There is concern that fixation of the syndesmosis in this position can result in persistent widening and predispose to instability, especially in plantar flexion and particularly if the screw is left in place or if ossification of the syndesmosis occurs41. We have found that placement of the screw with the ankle in 5 degrees of dorsiflexion leads to a satisfactory result.

The type of screw that should be used and the number of cortices that should be fixed continue to be debated. Opinions have varied as to whether screws should be used in only the lateral tibial cortex or in both the lateral and the medial tibial cortex. If screw removal is planned, probably neither the screw size nor the number of tibial cortices fixed is crucial, provided that the syndesmosis is reduced and stabilized properly. If screw removal is not planned, fixation through the lateral cortex only provides adequate fixation, and later, with weight-bearing, this unicortical screw will loosen rather than break, thereby allowing for the restoration of syndesmotic motion.

After fixation of the unstable syndesmosis, non-weight-bearing in a cast or a fracture brace for six to eight weeks generally is recommended. However, the time needed for healing of the syndesmotic complex is unknown. A very controversial topic is whether the syndesmotic screw should be removed before weight-bearing is resumed. Those who advocate removal of the screw emphasize that motion of the fibula with respect to the tibia, which is an important part of the normal motion and function of the ankle, will be altered if the syndesmotic screw is left in place41. The goal is to avoid a fixed and non-responsive syndesmosis caused by the replacement of the elastic ligaments with a stiff syndesmotic screw. Those who advocate leaving the screw in place note that there is no objective clinical evidence that this screw causes problems35. The screw usually loosens or breaks, permitting syndesmotic motion, and an additional operative procedure is avoided. The optimum time for removal of the screw is unknown. We are aware of several instances in which displacement of the fibula occurred after a syndesmotic screw was removed at six to eight weeks. The recommendations in the literature have ranged from six to twelve weeks41,60,63; it is probably better to leave the screw in place for the longer period of time. Our observation that, in some patients, symptoms seem to decrease after removal, loosening, or breakage of the syndesmotic screw suggests there may be individual differences in the ability of the ankle to tolerate a stiff syndesmosis.

Postoperative and Post-Injury Management
Early motion has been advocated after operative treatment of an ankle fracture56,58. Theoretically, early motion reduces intra-articular adhesions and improves long-term function. However, in a study of the results three months after internal fixation, no difference in motion or function was found between patients managed with early motion and those managed with several weeks of immobilization1,15,19,24. Stuart et al. reported that non-operative treatment of isolated fractures of the lateral malleolus with early motion in an air splint resulted in a greater range of motion and decreased time to rehabilitation compared with immobilization in a cast58. There was no difference in the time to union58. There is often concern that early weight-bearing after an ankle fracture could lead to a loss of reduction. This has not been observed after isolated lateral malleolar fractures or other stable injuries2. Similarly, when stable internal fixation has been achieved, early weight-bearing has not resulted in either late displacement of the fracture or a delay in healing1,3,19,24. Obviously, the decision as to whether stable fixation has been achieved and thus when weight-bearing can begin is affected by many variables, such as the degree of comminution and the quality of the bone, and must be made by the treating surgeon on a patient-by-patient basis.


   Pilon Fractures
Top
 Introduction
 Ankle Fractures
 Pilon Fractures
Overview
 References
 
Its name derived from the French word for "pestle" or "rammer," a pilon fracture involves the tibial articular surface. Rüedi and Allgöwer reported the results of open reduction and early fixation of pilon fractures53,54. Their basic treatment concepts included anatomical reduction and stabilization of the fibula, anatomical reduction of the articular surface of the distal part of the tibia, bone-grafting of the metaphyseal defect, buttress-plating of the tibia, and early mobilization of the ankle. They reported excellent results; however, most of their patients had sustained relatively low-energy injuries53,54. Application of these techniques to high-energy injuries, both open and closed, resulted in a high rate of complications, most commonly soft-tissue problems and infection43,63. As a result, a number of modifications of the original technique have been introduced in an attempt to reduce the complications associated with the treatment of high-energy and open pilon fractures10,12,43,50.

Classification
The classification system described by Rüedi and Allgöwer25,54, which is commonly used today, includes three types of fractures: type I is an undisplaced, T-shaped fracture of the distal end of the tibia that extends into the joint; type II is the same as type I but with displacement of the intra-articular components; and type III is a complex, intra-articular, multifragmental fracture. Ovadia and Beals43 added types IV and V to include fractures that extend into the metaphyseal and diaphyseal regions with more severe comminution, which is characteristic of many high-energy injuries50,61. The classification system of the AO/Orthopaedic Trauma Association is even more comprehensive and includes subdivisions that are based on the amount of comminution25. This system is very useful for research studies as it permits a more exact description of the injury and therefore allows better comparisons between studies.

As with any fracture, a thorough preoperative evaluation is essential for the effective treatment of a pilon fracture. It is important to understand the mechanism of injury because these factors determine the amount and type of energy imparted to the bone as well as to the soft tissues. The fracture pattern is dictated by the position of the foot and the talus at the time of impact. A straight axial load creates a more central depression with circumferential splitting of the distal part of the tibia. An inverted or everted position of the ankle at the time of impact creates a split, or often a split-depression, fracture with comminution and compression of the distal metaphysis.

The pattern and extent of the injury of the bone, the articular surfaces, and the soft tissues determine the techniques of fixation that should be used. The options range from non-operative treatment to the traditional open reduction and internal fixation as described by Rüedi and Allgöwer54. It must be remembered that the soft-tissue envelope around the distal part of the tibia is the limiting factor in the treatment of these injuries. The soft-tissue injury must be evaluated carefully, as postoperative problems with soft-tissue healing or coverage are associated with a substantial increase in the morbidity associated with this injury.

Anteroposterior, lateral, and oblique radiographs should be made. A traction radiograph of the injured extremity is helpful as traction and ligamentotaxis often cause the displaced fragments to be pulled back into position, which allows for a better definition and understanding of the fracture pattern (Fig. 3-A, 3-B, 3-C through 3-D). When the injury pattern is not seen clearly on plain radiographs, a computed tomographic scan can be made to allow for a better, three-dimensional evaluation of the injury. Precise preoperative planning and drawings made with use of the uninjured ankle as a template are helpful to ensure that the needed equipment and instruments are available. Careful planning also reduces the need for extensive soft-tissue dissection to allow the surgeon to see the fracture, reduces the operative time, and facilitates each step of the operation34.



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  		Figs. 3-A through 3-D: Radiographs showing the treatment of a pilon fracture. Fig. 3-A: Anteroposterior radiograph of a depressed comminuted pilon fracture.

 


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  		Fig. 3-B: Indirect reduction of the fracture with skeletal traction.

 


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  		Anteroposterior and lateral radiographs made after indirect reduction and stabilization with a cloverleaf plate.

 


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  		Anteroposterior and lateral radiographs made after indirect reduction and stabilization with a cloverleaf plate.

 
If more than a few hours have elapsed between the injury and the evaluation, the soft-tissue swelling will, as a rule, be too great to allow for an immediate open reduction and internal fixation. In this situation, skeletal traction, either with placement of the pin through the calcaneus or the application of an external fixator, should be used because soft-tissue recovery may take days or weeks and it is important to prevent skeletal shortening. Furthermore, indirect reduction with traction helps to realign the fracture surfaces, which makes subsequent internal fixation easier to accomplish.

The method that we commonly use to treat high-energy fractures involves the initial placement of an external fixation device with indirect reduction of the fracture. The fibula may or may not be fixed at the same time. After soft-tissue recovery has occurred, a limited open reduction and stabilization of the articular component is done with screws alone or with screws and a small buttress plate. The location of the incisions and the steps in reduction of the articular surface and the fracture fragments are based on the preoperative plan. Soft-tissue dissection should be minimized and, whenever possible, fragments should remain attached to the periosteum and the joint capsule.

The articular surface generally is reassembled from lateral to medial and from posterior to anterior. The anterolateral portion of the tubercle of Chaput usually is still attached to the anterior syndesmotic ligaments and is brought down into position at the time of fibular reduction. The anterolateral corner of this reduced fragment can be used as a guide for the restoration of tibial length. Any posterolateral or posterior fragments then are reduced to the anterolateral fragment. The remaining fragments, including any central depressed fragments, then are realigned. When necessary, the split medial malleolar fragment can be retracted posteriorly to allow for better visualization of the reduction of the articular surface. Temporary fixation is obtained with Kirschner wires, and the reduction is confirmed radiographically. Bone-grafting of any structurally deficient areas in the cortical or cancellous bone of the metaphysis then should be done. Autogenous bone grafts commonly are used. While allograft and synthetic bone materials have been used, the efficacy of these grafts in the treatment of pilon fractures has not been reported.

When plate fixation is planned, an anterior or anteromedial buttress plate is used, depending on the fracture configuration. Large spoon and T-plates no longer are recommended because they are too bulky and their use can lead to compromise of the overlying soft tissues. A 3.5-millimeter cloverleaf plate has a much smaller profile than the large-fragment-system plates but still has adequate strength to maintain reduction and can be bent and contoured relatively easily for positioning on the tibia (Fig. 3-C and 3-D). Cannulated screws can be placed independent of the plate, either through the wound or percutaneously, to secure isolated fragments. The importance of meticulous care of the soft tissues, including a tension-free closure, cannot be overemphasized.

The external fixator, if used, may be left in place for as long as is needed to achieve the specific goals of its use, such as soft-tissue stabilization, temporary buttressing, or definitive fixation. Weight-bearing should be delayed until there is radiographic evidence of bone-healing.

Open pilon fractures present an additional challenge. These injuries, like all open fractures, necessitate emergency débridement, irrigation, and stabilization. The typical wound associated with an open pilon fracture is a transverse distal anteromedial laceration. The proximal skin flap is contused, and use of the usual anteromedial incision may compromise its blood supply. When treating such an injury, it may be necessary to apply an external fixator, obtain indirect reduction, stabilize the fibula, and then perform the reconstruction of the articular surface through the open wound with use of cannulated screws for stabilization. This technique has been found to be less traumatic to the already injured soft tissues than the traditional extensile exposure11,12. Cancellous bone-grafting and even internal fixation can, if necessary, be delayed until four to six weeks later, when the soft tissues have stabilized and the risk of soft-tissue slough and infection is reduced.

Complications
Pilon fractures, especially those caused by high-energy trauma, have been associated with a high rate of complications10-12,25,43,50,61. Early postoperative problems have included skin necrosis, superficial and deep infection, and loss of fixation. Complications with fracture-healing have included delayed union or non-union of the metaphyseal-diaphyseal junction, varus or valgus malunion of the distal part of the tibia, and non-anatomical reduction or postoperative loss of reduction of the articular surface10,12,25,43. Stabilization of the anterolateral fragment and bone-grafting of the lateral border of the distal part of the tibia promote union and reduce the prevalence of both valgus malunion and non-union of this fracture. The prevalence of postoperative skin and wound problems has been reduced substantially with use of the technique of indirect reduction with external fixation and reconstruction of the articular surface with small plates or screws, or both10,11,25,27,34,59.

Post-traumatic osteoarthrosis may occur as a result of damage of the articular cartilage at the time of the injury and also has been associated with fractures in which a congruous articular surface was not restored or maintained10,11,25. Primary arthrodesis of the ankle rarely is indicated because the long-term outcome is not easy to predict. Although some patients may need an arthrodesis of the ankle because of symptomatic osteoarthrosis, others do fairly well despite radiographic signs of post-traumatic osteoarthrosis.


   Overview
Top
 Introduction
 Ankle Fractures
 Pilon Fractures
 Overview
References
 
The primary goal in the treatment of fractures of the ankle is to obtain union of the fracture and to restore normal function. Ankle fractures constitute a wide spectrum of injuries, ranging from undisplaced or minimally displaced stable fractures that can be treated non-operatively to displaced unstable fractures that necessitate operative intervention. While some controversies remain, the general principles and techniques for the operative treatment of ankle fractures are well established.


   Footnotes
 
*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 46, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1997.

{dagger}No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{ddagger}Department of Orthopaedics, University of Florida, Box 100246 JHMC, Gainesville, Florida 32610.

§Department of Orthopaedics, Johns Hopkins School of Medicine, 601 North Caroline Street, Baltimore, Maryland 21287.

¶Department of Orthopaedics, State University of New York at Buffalo, 462 Grider Street, Buffalo, New York 14215.


   References
Top
 Introduction
 Ankle Fractures
 Pilon Fractures
 Overview
 References
 

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