PILON FRACTURE

INTRODUCTION:

        A pilon fracture is a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint. With this type of injury, the other bone in the lower leg, the fibula, is frequently broken as well. A pilon fracture typically occurs as the result of a high-energy event, such as a car collision or fall from height.

Pilon is the French word for "pestle"—an instrument used for crushing or pounding. In many pilon fractures, the bone may be crushed or split into several pieces due to the high-energy impact that caused the injury.

In most cases, surgery is needed to restore the damaged bone to its normal position. Because of the energy required to cause a pilon fracture, patients may have other injuries that require treatment as well.

ANATOMY:

The two bones of the lower leg are the:

• Tibia—shinbone
• Fibula—smaller bone in the lower leg

The talus is a small foot bone that works as a hinge between the tibia and fibula. Together, these three bones—tibia, fibula, and talus—make up the ankle joint.

DESCRIPTION:

Pilon fractures vary. The tibia may break in one place or shatter into multiple pieces.

The severity of the injury depends on several factors, including:

• The number of fractures
• The amount and size of the broken bone fragments
• The amount each piece is out of place (displaced)—In some cases, the broken ends of bones line up almost correctly; in more severe fractures, there may be a large gap between the broken pieces, or the fragments may overlap each other.
• The injury to the surrounding soft tissues, such as muscle, tendons, and skin

If the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an "open" or compound fracture. This type of fracture is particularly serious because, once the skin is broken, infection can occur in both the wound and the bone. Urgent treatment is required to prevent infection.

CAUSES:

Pilon fractures most often result from high-energy trauma such as a car or motorcycle accident, fall from height, or skiing accident.

Doctors have seen an increase in pilon fractures since the introduction of air bags in motor vehicles. While air bags enable more people to survive high-speed car crashes, they do not protect the legs—so many of the survivors wind up with pilon fractures and other leg injuries.

SYMPTOMS:

Patients with pilon fractures usually experience immediate and severe pain. Other symptoms may include:

• Swelling
• Bruising
• Tenderness
• Inability to bear weight on the injured leg
• Deformity—your ankle may look angled or crooked

DIAGNOSTIC METHODS:

·         X-rays. X-rays provide images of dense structures, such as bone. X-rays of the leg, ankle, and foot are commonly done to evaluate a pilon fracture. An x-ray can show if there is an injury to your bones or if the joints in your ankle are out of place.

·         Computed tomography (CT) scans. A CT scan can provide valuable information about the severity of the fracture by helping your doctor see the fracture lines more clearly. A CT scan will also help your doctor plan your treatment. Your doctor may order a CT scan right away, or may wait until later in your treatment—after an external fixator is applied.

TREATMENT:

·         Nonsurgical Treatment

Nonsurgical treatment may be recommended for stable fractures in which the pieces of bone are not displaced or are minimally displaced.

It may also be recommended for patients who do not do a lot of walking or for patients who are at higher risk for surgical complications. For example, patients with severe osteoporosis, heart disease, or other medical concerns may not be able to tolerate surgery.

Nonsurgical treatment may include:

Ø  Splints and casts. In most cases, your doctor will first apply a splint to hold your ankle in place. Once the swelling goes down, he or she will replace the splint with a short leg cast. To provide effective support, your cast must correctly fit your ankle. For this reason, as the swelling in your ankle decreases, you may need frequent cast changes.

Ø  Monitoring. Doctor will closely monitor the healing of your fracture. During this time, you will need to return regularly for follow-up x-rays to make sure your ankle remains stable.

Ø  Recovery. You will most likely be unable to bear weight on your ankle for up to 12 weeks after your injury. During this time, your doctor may recommend that you use crutches or a walker. After 6 weeks, your doctor may replace your cast with a removable brace. This will offer protection while your ankle continues to heal

·         Surgical Treatment

Surgery is commonly recommended for unstable fractures in which the bones are out of place.

·         Open Reduction and Internal Fixation

During this operation, the displaced bone fragments are first repositioned (reduced) into their normal alignment, and then held together with screws and metal plates attached to the outer surface of the bone.

·         Timing of Surgery

If you have significant swelling or blisters, your doctor will delay your surgery until the swelling goes down. Performing surgery too soon increases your risk for infection or problems with your incision. Your surgery may be delayed for up to 2 weeks or more, depending on how long it takes for the swelling to go down.

Doctor may place your ankle in a splint until your surgery, or recommend that you have an initial smaller surgery to protect your ankle while waiting for the second surgery.

·         External Fixation

Doctor may apply an external fixator to hold your pilon fracture in place and stabilize your ankle until your second surgery can take place.

REHABLITATION: 

·         Weight Bearing

Most patients are not able to put all of their weight on their injured ankle for 2 to 3 months. Doctor may recommend that you use crutches, a cane, or a walker during this time.

·         Physical Therapy

Once you are allowed to start moving your ankle, doctor may place it in a removable cast or brace so that you can begin physical therapy. Specific exercises will help improve the range of motion in your ankle. Exercises to strengthen the supporting muscles will be added around 6 weeks after surgery.

As you transition to wearing regular shoes, you will gradually stop wearing your brace. By 4 months after surgery, most patients no longer need a walking aid.

Because your ankle can continue to improve for up to 2 years, it is important to continue the exercises even after you have completed the formal physical therapy program.

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