OPEN REDUCTION AND INTERNAL FIXATION: PLATING PILON

Indications

• Fractures with > 2 mm articular incongruity.

• Fractures with significant displacement of the metaphysis.

• Reconstructable fractures (joint fragments that are large enough to hold small fragment screws).

• Compartment syndrome.

• Adequate soft tissue envelope.

Pre-operative planning

Clinical assessment

• Mechanism of injury (fall from a height, skiing injury, motor vehicle accident, forward fall with a trapped foot).

• Look for associated injuries.

• Thoroughly assess the soft tissue condition.

• Look for the presence of an open injury.

• Assess the neurovascular status of the extremity.

• Look for early signs or symptoms of compartment syndrome.

• Review patient's past medical history and recognize the presence of existing medical conditions (diabetes, osteoporosis, vascular disease) that can modify the plan of treatment).

• Displaced or dislocated fractures must be reduced immediately.

Radiological assessment

• Standard high-quality anteroposterior (AP), lateral, 45° external rotation and mortise views of the ankle.

• CT scan: provides information regarding the fracture pattern, the number and location of the cortical fragments, the extent of articular comminution and the amount of articular displacement (Fig. 12.35a,b,c).

Timing of surgery

• Open fractures are treated on an emergency basis.

• Generally it is determined by the condition of the soft tissues.

• Simple fractures or fractures with minimal soft tissue injury can be definitively stabilized in 6–8 hours.

• For other types of fractures a 6–12 day delay is preferable.

• The use a joint bridging external fixator with elevation of the limb in the meantime is mandatory.