Conservative treatment: skeletal traction
Conservative management is based on step-by-step skeletal traction. The process includes several important steps aimed at correcting various types of displacement.
Main traction Traction is applied along the axis of the lower leg. For this purpose, a Kirschner wire is inserted through the calcaneus strictly in the frontal plane. The initial reduction weight is 5–7 kg. Once reduction is achieved (usually taking 4 to 7 days), the weight is necessarily reduced to a maintenance load of 3–4 kg.
Correction of displacements
- Reduction of posterior foot dislocation: Requires placing an additional Kirschner wire through the supramalleolar region of the tibia (in the frontal plane) with vertical downward traction using a weight of 1–3 kg. At the same time, counter-traction is necessary: the calcaneus is elevated via the first wire and rigidly fixed to the Böhler splint arch. An alternative, but less effective option is using a plaster pad instead of the supramalleolar wire.
- Posterior tibial margin displacement: Corrected by bringing the foot into a position of dorsiflexion. This allows the bone fragment to be brought down and pressed against its native bed. To achieve flexion, either a wire inserted through the metatarsal bones or a special plastic or plaster foot support is used. When using a foot support, strict skin monitoring is required to prevent pressure sores.
Skeletal traction is maintained for 4 weeks, after which the patient is switched to plaster immobilization. The total fixation period is up to 2.5–3 months.
Surgical treatment: indications and principles
Surgical intervention is indicated when closed restoration of joint surface congruency is impossible. All suprasyndesmotic fractures (type C) and displaced lateral malleolus fractures (especially rotational ones) are also operated on, as closed reduction of the latter is practically unfeasible due to the multidirectional pull of muscles.
Reasons for conservative reduction failure:
- Soft tissue interposition or rotation of the fragment around its axis in the medial malleolus area.
- Inability to appose the leg bones due to complete rupture of the distal tibiofibular syndesmosis or overly delayed reduction attempts.
Timing and principles of osteosynthesis The optimal window for surgery is considered to be the first 6–8 hours — before epidermal blisters and true edema develop (initial swelling is solely due to a hematoma). If time is missed and edema has increased, the intervention is delayed until tissue condition improves.
A key stage of the surgery is precise reduction and fixation of the lateral malleolus with a special plate. This exact step is critically important for restoring the correct anatomy of the ankle joint. As a rule, this eliminates the diastasis of the distal tibiofibular syndesmosis, which is additionally fixed with a cancellous screw in the horizontal plane.
Strategy for open and contaminated wounds
If the fracture is accompanied by complete foot dislocation and skin damage (open fracture-dislocation), the infection risk is extremely high. Under such conditions, the use of classic internal plate fixators is inappropriate.
After surgical wound debridement, reduction is completed using one of the following methods:
- Application of a compression-distraction apparatus (Ilizarov/external fixator).
- Percutaneous wire fixation. In this case, transarticular fixation is used: wires are inserted through the calcaneus, transit through the ankle joint, and anchor in the tibia.
Postoperative management
The limb is immobilized with a split plaster cast up to the knee joint. When the swelling subsides and sutures are removed, the cast is changed to a circular (solid) one.
Timing of hardware removal:
- Percutaneous wires protruding through the skin are removed after 2–3 weeks.
- The syndesmotic screw is removed strictly before starting range-of-motion exercises in the joint, otherwise it will disrupt ankle biomechanics.
- The external fixation device (distraction apparatus) is dismantled after 1.5–2 months (rehabilitation begins as early as the day after surgery).
- Internal plates are removed only after complete bone healing (consolidation) of the fragments and completion of the rehabilitation course.
Long-term complications
Inadequate treatment (residual displacement, incongruity, syndesmosis diastasis) leads to severe consequences.
- Post-traumatic deforming osteoarthritis: manifests as pain, restricted function, decreased weight-bearing capacity, and chronic edema. For moderate symptoms, NSAIDs, physiotherapy, or arthroscopy are prescribed. In severe cases, the only solution is arthrodesis (fusion) of the joint.
- Sudeck-Turner neurodystrophic syndrome: a pathology accompanied by burning pain. The pathogenesis is based on the rapid development of osteoporosis of the foot bones and distal tibial metaepiphyses due to joint damage.
Briefly: answers to topical questions
What classifications are used to assess pilon fractures?
Pilon fractures are assessed using the Ruedi-Allgower classification and the classification by D. Leonetti and D. Tigani.
- Ruedi-Allgower classification — divides injuries into three types depending on the presence of fragment displacement and impaction of the tibial articular surface.
- Leonetti and Tigani classification — based on CT scan data and distinguishes four types of fractures, taking into account extension to the articular surface, magnitude of displacement, number of fragments, and fracture plane orientation.
The universal AO/OTA classification for segment 43 (distal tibia) is also applicable.
What is the complete sequence (stages) of osteosynthesis for a pilon fracture?
Osteosynthesis for a pilon fracture includes mandatory fixation of the lateral malleolus and tibiofibular syndesmosis, however, the complete sequence for the tibia is not described as a single rigid chain.
- Fixation of the lateral malleolus — a key step performed with a special plate for precise reduction and restoration of joint congruency.
- Reduction of the syndesmosis — diastasis of the distal tibiofibular syndesmosis is usually corrected automatically upon reduction of the lateral malleolus.
- Fixation of the syndesmosis — performed with a cancellous screw in a horizontal direction.
Screws, wires, plates, and wire sutures are used for the osteosynthesis of the malleoli and tibial margins.
What radiological criteria indicate successful reduction of the pilon articular surface?
Specific numerical radiological criteria for successful reduction of the pilon articular surface specifically are not provided in the supplied materials. It is indicated that the goal is precise reduction and restoration of articular surface congruency. For malleolar fractures, the adequacy of reduction is assessed by eliminating gross fragment displacement and restoring ankle joint congruency; control is performed via radiographs in anteroposterior and lateral projections.
The "Key to the Joint" rule: precise fixation of the lateral malleolus is the main stage of osteosynthesis, which in itself often eliminates syndesmosis diastasis.
Class and exam questions
Why should plates not be used in open pilon fractures?
In contaminated wounds, the risk of infection is extremely high, therefore the use of internal plate fixators is inappropriate. Preference is given to external fixation devices or percutaneous wires.
When should a positional screw be removed from the syndesmosis?
The lag/cancellous screw from the distal tibiofibular syndesmosis is removed earlier than other fixators — strictly before starting range-of-motion exercises in the ankle joint.
How to correct posterior tibial margin displacement conservatively?
It is necessary to bring the foot into dorsiflexion using a wire through the metatarsal bones or a special foot support, which allows the fragment to be lowered into its correct position.
What else to study on this topic
- Specifics of applying a compression-distraction apparatus in open injuries
- Biomechanics of lag screw function in the tibiofibular syndesmosis zone
- Ankle arthrodesis technique for severe osteoarthritis
- Pathogenesis and management protocols for pain in Sudeck-Leriche syndrome
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