Pilon Fractures

First described by Destot ³⁵ in 1911, ankle fractures that involve the weight-bearing articular surface, or floor, of the distal tibia are known as pilon fractures. Bonin,¹¹ in 1950, described the same fracture as a “plafond” fracture because the fracture disrupted the roof of the ankle joint. In 1968, Rüedi et al⁸⁶ published their landmark article and were the first to describe the fracture, its treatment, and a prognostic classification. Since that time, the severity of this injury, the complexity of treatment methods, and the limitations of management have been well documented and still pose a challenge to the orthopaedic surgeon. These injuries are rare and comprise less than 1% of all lower extremity fractures but involve between 5% and 10% of tibia fractures.^9,18,83

Anatomy

The articular surface of the distal tibia is an irregularly shaped rectangle and articulates with the dome of the talus (Fig. 36-1). The surface is wider anteriorly than posteriorly, and it is concave in both the coronal and sagittal planes.⁹¹ This articular surface is continuous with the medial malleolar articular surface, which lies at an angle of about 90 degrees to the tibial plafond and extends about 1.5 cm distal to it. The medial aspect of the distal fibula also articulates with the lateral aspect of the talus to complete the ankle mortise (Fig. 36-2). At the metaphysis, the cortex is thin and filled with relatively dense cancellous bone, with the strongest bone near the subchondral plate.

Figure 36-1 The articulating surface of the distal tibia. Note the lesser articulations with the malleoli. (From Heim U: Morphological features for evaluation and classification of pilon tibial fractures. In Tscherne H, Schatzker J, editors: Major fractures of the pilon, the talus, and the calcaneus, Berlin, 1993, Springer-Verlag, pp 29-41.)

Figure 36-2 A, The articular surface should be equidistant throughout the joint (arrows). B, The incisura, where the fibula articulates with the distal tibia (1) and the posterior malleolus (2). C and D, The central axis of the leg (red line) runs through the center of the plafond and the talus.

The lateral surface of the distal tibia forms a triangular fibular notch where the tibia and fibula articulate.¹² The anterior tibiofibular ligaments arise from the Chaput tubercle on the anterolateral tibia, anterior to the fibular notch; these ligaments insert on the Wagstaffe tubercle of the distal fibula.⁷³ The posterior portion of this articulation serves as the attachment for the posterior tibiofibular ligament, whose ligaments are oriented inferior and laterally (Fig. 36-3). The remainder of the syndesmotic complex consists of the strong interosseous ligament, a distal continuation of the interosseous membrane, and the inferior transverse ligament, running deep to the posterior tibiofibular ligament between the tibia and fibula.¹²

Figure 36-3 Posterior aspect of ankle joint showing various ligamentous complexes. (From Warwick R, Williams P, editors: Gray’s anatomy, ed 35, London, 1973, Longmans.)

Internal tibial torsion of approximately 25 degrees is seen from the middiaphyseal medial surface of the tibia to the flat surface of the medial malleolus (Fig. 36-4).⁵⁸ The anteromedial surface of the distal metaphysis is concave; the radius of curvature of this supramalleolar curve is approximately 20 cm.⁵⁸ This curved area extends 8 to 12 cm proximal to the medial malleolus, depending on the length of the tibia.

Figure 36-4 A, Tibial torsion. At the distal end, the torsion is approximately 25 degrees. As one moves up the leg, the torsion becomes more extreme, approaching 45 degrees. B, Radius of curvature of the distal medial tibial shaft. (A, Modified from Weber BG, Magerl F: The external fixator, Berlin, 1985, Springer-Verlag. B, Modified from Mast J, Jakob R, Ganz R: Planning and reduction technique in fracture surgery, Berlin, 1989, Springer-Verlag.)

The skin covering the distal tibia receives its direct blood supply from the underlying fascia via perforating arteries originating from the dorsalis pedis, posterior tibial, and peroneal arteries.¹⁰⁰ The superficial venous system of the leg includes the greater saphenous vein, which travels with the saphenous nerve anterior to the medial malleolus up the medial surface of the tibia to the knee. The lesser saphenous vein, the lesser saphenous nerve, and the sural nerve all run posterior to the lateral malleolus, traveling proximally to the center of the posterior aspect of the leg between the medial and lateral heads of the gastrocnemius.⁹¹ The primary branches of the anterior and posterior tibial artery provide the main extraosseous blood supply to the tibia.¹² It is well known that the extraosseous blood supply nourishes the outer third of the cortex, and the inner two thirds receives its blood supply from the nutrient artery and its medullary branches.⁴⁹

Mechanism of Injury

Many authors have speculated on the mechanism of a pilon injury.6,35,40,86 Böhler⁶ was first to note that the position of the foot at the time of impact was critical to the morphology of the fracture. Rüedi,⁸⁶ however, expanded on this, as did Trojan and Jahna.¹⁰⁴ Rüedi⁸⁶ was the first to describe in detail the combination of an axially applied load in combination with foot position. If the vertical compression force is applied to a plantigrade foot, a central depression occurs, whereas if the force is applied with the foot in either dorsiflexion or plantar flexion, the fracture results in anterior or posterior malleolar injuries, respectively (Fig. 36-5). Aside from the axial load, additional forces can be created to give each fracture its own personality, including bending, rotational, and shearing forces. These fractures also vary by the amount of energy that they absorb, ranging from high-energy injuries (motor vehicle accidents) to lower-energy injuries (simple fall). The higher the energy of the injury is, the greater the likelihood of comminution, displacement, and cartilage injury.

Figure 36-5 Mechanism of injury according to Böhler is a combination of axial load plus the position of the foot at the time of impact. A, Injuries with plantar flexion. B, Injuries with dorsiflexion. (Modified from Böhler L: Die Technik der Knochenbruchbehandlung, ed 13, Vienna, 1951, Maudrich.)

Fracture Classification

The purpose of a classification is to aid the surgeon in selecting a treatment method and to provide prognostic and outcomes based on the fracture pattern. These two principles are essential in the development and use of creating a reliable classification system. Early on attempts at a classification system for pilon fractures were made. Rüedi et al,⁸⁴ Kellam and Waddell,⁴² Mast et al,⁵⁹ and the Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF)⁶⁶ have all used plain radiographs to classify pilon fractures. The early radiographic classifications of Böhler,⁶ and Bonin¹¹ were based on mechanism of injury, and the position of the foot and the direction of the force applied were important criteria.

As Rüedi et al ⁸⁶ pointed out in their seminal work, these early classifications did not assist the surgeon in either recognizing the severity of the injury, planning the surgical approach, or determining the outcome. Instead, Rüedi et al⁸⁶ popularized an easily reproducible classification based on the amount of joint comminution (Fig. 36-6). Type I injuries were cleavage fractures without displacement, type II injuries were displaced fractures that consisted of large osteochondral fragments without comminution, and type III injuries involved all degrees of comminuted and impacted fractures. Although the presence of a fibular fracture was important for treatment, this did not alter the outcome after surgical intervention.

Figure 36-6 Rüedi classification of pilon fractures. I, Nondisplaced; II, large articular fragments; III, highly comminuted. (From Rüedi T, Matter P, Allgower M: [Intra-articular fractures of the distal tibial end]. Helv Chir Acta 35:556-582, 1968.)

Kellam and Waddell ⁴² described two fracture patterns. Type A was a rotational pattern, and type B was the classic compressive pattern. In their study, the rotational pattern was found to be less common than the compressive fracture and to have a substantially better prognosis after surgery.

Müller et al ⁶⁶ published the Comprehensive Classification of Fractures (CCF) in an effort to allow surgeons to compare the results of similar fractures. In 1996, the Orthopaedic Trauma Association (OTA)⁷⁰ published a similar classification that modified the original Rüedi classification scheme. These fractures are now considered 43-A, 43-B, and 43-C fractures (Fig. 36-7). All these systems are based on plain radiographs.

Figure 36-7 Orthopaedic Trauma Association classification of pilon fractures, groups 43-A to 43C. (From Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 10[Suppl 1]:v-ix, 1-154, 1996.)

Since that time, recent scientific articles have been published that question the reliability and reproducibility of the Rüedi classification, specifically its accuracy in determining the severity of bone injury and the displacement of fracture fragments.20,56,96 All authors concluded that the same fracture could not be reliably and consistently classified by different reviewers, beyond the most basic fracture patterns, and therefore were of limited use in research.

Tornetta and Gorup ¹⁰² described the advantages of adding computed tomography (CT) imaging to the preoperative planning of these fractures. Using plain films, the authors first classified the fracture according to Rüedi and then reviewed the CT scan to determine whether any further useful information was obtained, specifically the direction of the major fracture line, the degree of comminution, and the amount of impaction. Although a more accurate assessment of the fracture was possible in every case, the most important finding was that the direction of the primary and secondary fracture lines could be more clearly identified. This caused a change in the surgical planning and care in 64% of patients. Most recently, Topliss et al¹⁰¹ have used CT scans to define the anatomy of the fracture and improve on the classification. They have documented a lateral disruption fracture, where the lateral border of the talus and the distal fibula was disturbed. This finding was strongly associated with an intact fibula and indicated a likely disruption of the talofibular joint. These studies have supported the routine use of CT scans to aid in understanding the fracture pattern and surgical planning. However, despite the additional information gathered from CT scans, there is still a current lack of a classification system that allows us to adequately correlate long-term outcomes for these difficult fractures.⁹⁶

Associated Injuries

Tibial pilon fractures are often the result of high-energy trauma and can be associated with injuries to the ipsilateral or contralateral limb. A thorough evaluation should be performed of the trauma patient, and temporary stabilization of injuries should be performed on initial evaluation. Injuries to the ipsilateral limb, such as tibial shaft or plateau, talus fractures, and calcaneal fractures, may affect the initial treatment by limiting possible temporary fixation sites. Also, these injuries can affect surgical treatment strategies when proceeding with definitive fixation in terms of implant selection and patient positioning.

The most common injury associated with pilon fractures are injuries to the talus. There is a wide variance of injuries from comminuted talar body and neck fractures to small osteochondral injuries. Although these injuries are relatively infrequent, articular damage, such as delamination or gouging of the talar cartilage, is not uncommonly seen. There is no literature that shows how this affects the long-term prognosis of the ankle joint.

Diagnosis and Radiologic Evaluation

The diagnosis is made clinically and radiographically. The clinical appearance is that of an ankle fracture that may be either open or closed. Normal orthopaedic protocols should be used for managing the injury in the emergency department. Urgent recognition of a fracture-dislocation of the ankle is essential, and immediate reduction and splinting should be performed to minimize further injury to the soft tissue envelope. Initial radiographs, including imaging of the ankle and tibia plus fibula, should be performed. The plain films, when studied carefully, offer a wealth of information about the fracture (Fig. 36-8). When evaluating these radiographs, the surgeon should determine whether or not the fibula is fractured, the degree of articular comminution, and the amount and location of fragment impaction. Any obvious subluxations or dislocations at the tibiotalar joint, talofibular joint, or the syndesmosis should be noted, as well as any associated injuries to the hindfoot.

Figure 36-8 Radiographs of an intraarticular distal tibia fracture. A, Anteroposterior view showing tibial articular impaction into the metaphysis. Also, there is a lateral talar osteochondral fracture. B, Lateral view showing a displaced posterior malleolar fragment.

CT scans should not routinely be obtained until after the limb has been stabilized (preferably with a spanning external fixator) because the anatomy will be distorted. Once the fracture has been pulled out to length, the CT scan becomes a useful preoperative planning tool (Fig. 36-9). The CT scan allows the surgeon to evaluate missed lesions, such as tubercle of Chaput avulsions, coronal and sagittal splits, syndesmotic disruption, coronal or sagittal fractures of the distal fibula, and bony damage to the talar dome. All of these findings are important for planning subsequent treatment (Fig. 36-10). In the setting of a pilon fracture that may be amenable to limited fixation of the tibia in conjunction with external fixation, a preoperative CT scan may be useful.

Figure 36-9 A and B, After the spanning frame is placed, repeat radiographs are taken to verify that the ligamentoaxis has pulled the fracture into reasonable alignment. Radiographs show reduction of the tubercle of Chaput (*) and improved reduction of the talus under the mortise. C, Computed tomographic (CT) scan after reduction shows the intraarticular nature of the fracture. The medial malleolar (MM) and posterior malleolar (PM) fragments have been reduced. D, CT scan indicates that the joint surface has been broken into multiple fragments.

Figure 36-10 A and B, Anteroposterior (AP) and lateral radiographs after placement of spanning frame. Careful assessment shows disruption of anterolateral fragment on the AP view (black arrow), as well as an intraarticular step-off on the lateral (white arrows). Note the impacted fragments (*), only seen on the lateral view. C and D, Coronal and sagittal computed tomography (CT) reconstructions show the articular damage much more clearly than plain films. E, Coronal CT scan shows split and impaction of the joint. Upper right inset shows transverse CT at the level of the metaphysis. Although this view shows impaction, it is hard to visualize the fracture patterns. Lower right inset shows transverse CT at the level of the joint. The primary fracture line can be seen running anterior to posterior, with secondary lines breaking off the tubercle of Chaput (TC), as well as a nondisplaced fracture of the medial malleolus (MM). Also note the centrally impacted articular surface (*). In this CT scan, the only fragment that remains anatomic is the posterolateral corner (PL). The surgeon must rebuild the joint around this fragment. F, fibula.

Historical Treatment Options

Successful operative treatment for pilon fractures was initially described in the 1950s, mostly for lower-energy rotational injuries of the ankle occurring from ski injuries. Immediate fixation of these injuries, popularized by Rüedi et al 83,86 and published in the European literature, showed good results after 9 years of follow-up in a substantial number of patients. These authors published their data in the English literature in 1979.⁸⁵

In 1986, Ovadia and Beals ⁷¹ published their results on 145 pilon fractures. The methods of treatment were divided into two groups: open reduction and internal fixation according to the AO technique and other methods. The best results were obtained by open reduction and internal fixation. In their classic 1987 textbook, Schatzker and Tile⁹² stated that pilon surgery should be performed soon after the injury, before the development of fracture blisters, incorporating open wounds into the surgical incisions whenever possible. As a result of these publications, internal fixation of these fractures became the standard of care in the United States by the 1990s.

Unfortunately, many fractures in the United States were a result of higher-energy motor vehicle injuries that resulted in soft tissue compromise as well. Many surgeons were also unfamiliar with the soft tissue management techniques needed to obtain a successful operative outcome, and these fractures had high complication rates.

In 1992, McFerran et al ⁶¹ reported on their operative experience with pilon fractures over a 5-year period. They experienced a 40% complication rate when immediate internal fixation was performed, and 21 of 52 fractures required 77 more procedures.

Teeny and Wiss,⁹⁷ in a retrospective study, evaluated 60 plafond fractures treated by internal fixation and reviewed over a follow-up period of 2.5 years. Sixty percent of the fractures were the result of high-energy trauma. Poor results occurred in 50% of the cases. The deep infection rate in Rüedi type III fractures was 37%. Of importance, the deep infection rate statistically correlated with the presence of a postoperative wound dehiscence or skin slough but not with the presence of an open fracture. The authors concluded that if anatomic reduction without soft tissue complications could not be predicted preoperatively, consideration should be given to alternative types of treatment.

Using the techniques of minimal internal and external fixation of tibia fractures,⁹⁵ Bone et al¹⁰ presented a series of high-energy pilon fractures treated with isolated lag screws or small plates, or both, for the articular reduction, coupled with external fixation as a neutralization device across the ankle, to align the metaphyseal components of the fracture. The external fixator was then left in place until the tibial shaft component of the fracture healed. The authors noted that their complication rate was decreased and concluded that this was due to better soft tissue management secondary to the external fixator, but they stressed the important need for anatomic reconstruction of the articular surface.

Tornetta et al ¹⁰³ furthered this concept by using isolated lag screws combined with a hybrid fixator so that early motion of the ankle joint could be maintained. The authors first operatively stabilized the fibula and then performed an open reduction of the articular surface using lag screws. After this was accomplished, fixation of the distal metaphysis to the tibial diaphysis was performed using a hybrid ring fixator. The authors concluded that the method offered a low complication rate and had the added advantage of early joint motion. Similar results using this technique were subsequently described by many authors.^8,30,54,87

Although soft tissue complications were minimized as a result of this technique, many authors began to use percutaneous, rather than open, reduction of the joint surface, either with cannulated screws or with small-wire techniques.4,61 Unfortunately, complications were not eliminated. Anglen¹ reported on 61 pilon fractures treated by a single surgeon. Fracture stabilization was accomplished with the use of a hybrid external fixator (n = 34) or with internal fixation (n = 27). Patients treated with hybrid fixation had lower clinical scores, slower return to function, a higher rate of complications, more nonunions and malunions, and more infections. The author concluded that hybrid fixation did not seem to solve the problems inherent in severe pilon fractures, and the optimistic results reported in the literature using frames did not hold true in his series.

Hutson and Zych ⁴⁰ reported on the rate of infection associated with tensioned wire fixators. They noted a 7% rate of pin-tract infections, one case of septic arthritis, and one deep infection. When performing a meta-analysis of published data on tensioned wire frames in the treatment of pilon fractures, they noted an overall pin-tract infection rate of 21%. Finally, Vives et al¹⁰⁷ documented the risks associated with tensioned wire placement during frame application, including a 55% rate of piercing of at least one tendon and an 8% to 10% rate of impaling neurovascular structures.

Complications included malreduction of the articular surface; malunion or nonunion of the tibial shaft; pin-tract, soft tissue, and bone infections; and damage to the neurovascular and tendinous structures about the ankle. As a result of these complications, consideration was again given to open reduction using plates, but in a staged manner. This concept was not new. Schatzker and Tile ⁹² noted that in cases of massive swelling “surgery is hazardous and must be avoided” (their italics). They suggested the use of a spanning external fixator and a delay of 7 to 10 days before attempting internal fixation. Similarly, in 1990, Höntzsch et al³⁹ documented the advantages of two-stage treatment, with a delay in surgical treatment of 2 to 3 weeks in 50 pilon fractures.

In February of 1999, two landmark articles were published that reported on the results of a staged management for high-energy pilon fractures, one by Sirken et al ⁹⁴ and the other by Patterson and Cole.⁷⁴ Both papers used a protocol in which temporary external fixation was used in conjunction with immediate fixation of the fibula, if indicated. Definitive fixation was delayed until the soft tissue envelope had improved, to allow definitive reconstruction, typically between 10 to 14 days. Both studies showed decreased wound complications and improved outcomes for these severe injuries. Staging of the procedure allows the surgeon to stabilize the injury and allows the soft tissues to improve such that soft tissue complications are minimized at the time formal open reduction and internal fixation is performed.

More recently, this technique has been modified to allow partial fixation of the tibial fracture while minimizing soft tissue complications. Dunbar et al ²² described a technique where tibial pilon fragments that had proximal extensions were treated with limited internal fixation through small incisions. The goal of this technique was to restore the anatomic alignment of the fragments with respect to length and rotation, which can often be difficult to obtain at the time of delayed fixation. Ketz and Sanders⁴³ reported on pilon fractures that had displaced posterior malleolar fracture fragments. These fractures were treated with a staged protocol that used limited posterior fixation of the tibia in conjunction with fibular fixation, using a posterolateral approach. The results showed improved overall reductions with no wound complications in 28 patients.

Recent studies have evaluated the role of percutaneous plating techniques for pilon fractures.2,32,34 The majority of these studies have used precontoured medial tibial locking plates. These studies reported low rates of wound complications, but there were a high number of delayed unions or nonunions, with one study having 35% healing after 6 months and a 10% nonunion rate.³⁴ Hasenboehler et al³² had 4 of 30 patients heal at greater than 6 months, with one failure of fixation and two nonunions. Low soft tissue complications or infections were seen with both studies. Percutaneous techniques are useful in reducing the soft tissue trauma and remain a viable option for the treatment of pilon fractures, particularly in minimally displaced or nondisplaced fractures. However, there is often poor visualization of the joint, and articular reduction should not be compromised when using these techniques.

Currently, there are numerous treatment strategies for pilon fractures that exist. The “personality” of the individual fracture and the surrounding soft tissues, in a sense, dictate which techniques can be used. External fixation, spanning, and nonspanning techniques are still a viable option with or without formal articular reduction using lag screw fixation. The most commonly used approach is staged reconstruction with initial external fixation and delayed fixation. Limited tibial fixation can also be implemented in the initial stage with minor risk of wound complications. Current trends are aimed at fragment-specific fixation with smaller, lower-profile implants and multiple, even more soft tissue–friendly approaches.

Current Treatment Options

Staged Open Reduction and Internal Fixation

Portable Traction

When planning to treat pilon fractures with associated fibula fractures surgically, anatomic reduction of the fibula provides restoration of length and rotation of the fracture. It also can indirectly reduce tibial fragments resulting from ligamentotaxis.¹⁰⁶ This is performed in conjunction with ankle-spanning external fixation. Surgical fixation of the fibula is best achieved with a plate and screw construct because the fracture pattern is often comminuted and malreduction is a concern. Fixation of the fibula with an intramedullary device is rarely recommended because it can lead to angulation, rotation, or shortening of the fracture, which can affect the surgeon’s subsequent ability to obtain an anatomic reduction of the tibia. Although fixation of the fibula is typically performed with external fixation initially, the authors would like to stress that it should be the treating surgeon who performs this aspect of treatment. This will ensure that further incisions or treatment strategies are not compromised because of a previous incision or malreduction from another surgeon.

Although a standard midlateral extensile incision is recommended for fibular fixation, all anterior incisions should be drawn out initially, to verify that the distance between the anterior and lateral incisions is 5 to 7 cm at a minimum. This will prevent vascular compromise of the interposed flap ⁹² and might require the surgeon to move the fibular incision posteriorly when reducing and fixing the fibula.

For fracture patterns that have a displaced posterior malleolar fragment (type III), consideration can be given to performing fibular fixation and limited posterior tibial fixation through a posterolateral incision. The advantage of this technique is that it allows anatomic reduction initially and provides a stable buttress to allow the surgeon to build the fracture in a “back to front” fashion. In a sense, this converts a C-type fracture (complete articular) to a B-type fracture (partial articular). The fragment typically shortens and rotates and so cannot be reduced appropriately with external fixation alone. Obtaining an accurate reduction of this posterior fragment can be difficult through standard anterior incisions because alignment must be obtained indirectly. Indirect reduction using closed or percutaneous methods is often difficult to perform because of impaction and three-dimensional rotation of the fracture fragments.

Pin placement distally depends on the type of frame used. A simple A-frame, delta, or traveling traction frame requires a calcaneal transfixion pin.39,53 Unilateral, multiplanar frames require medial half-pins, with one placed in the talar neck and one placed in the calcaneus. Although the calcaneal pin should be placed with care to avoid the neurovascular bundle, the talar pin must be placed to avoid any planned anteromedial incisions. Caution should be used with talar neck pins because they are typically placed within the ankle joint. With all frames, the proximally placed tibial pins should be away from the planned incisions to prevent pin-tract colonization, which could infect the surgical site. Because these frames are rarely left on the patient for longer than 3 weeks, pin-tract complications are rarely seen.

When placing frames, the surgeon should verify that the tibial shaft reduction is in an acceptable alignment. Posterior subluxation of the talus and hindfoot will lead to pressure necrosis of the anterior skin as the distal end of the proximal tibial shaft digs into the anterior tissue. When using a calcaneal transfixion pin, the surgeon must make certain that an equinus deformity will not occur at the ankle and associated midfoot sag. This can be accomplished by placing additional pins in the forefoot or applying a commercially available foot plate. This concept is particularly important if the soft tissue envelope may not be ready for an extended period of time.

If the fracture is isolated, reliable patients may be sent home non–weight bearing on crutches and followed in the office. During that time, additional studies, such as CT scans, may be ordered, and surgical intervention may be planned once skin wrinkling is seen, generally at 10 to 14 days.42,54

Regardless of the technique used, the patient must be given intravenous antibiotics immediately before surgery is begun (usually cefazolin [Ancef] 1 g).

Although many surgeons prefer not to use a tourniquet, we believe that it is impossible to truly evaluate an articular reduction unless visualization is maximized. Thus, after the femoral distractor pins are placed and before an incision is made, an Esmarch bandage is used to exsanguinate the limb, and a high-thigh tourniquet is inflated to 325 mm Hg. The tourniquet may be left inflated for 2 hours without any adverse effects.

Approach

Overview

During the initial stage of treatment, plating of the fibula fracture is generally through a standard lateral approach; the surgeon must be aware of the placement of the tibial incision before the lateral incision is made. Skin bridges between the two incisions must not be less than 5 cm to prevent wound necrosis of the flap between them. Limited fixation of the fibula and the posterior tibia may be performed through a posterolateral approach. The placement of the posterolateral incision does not compromise any future anterior or medial approaches.

Late-stage fixation can be performed through a variety of approaches to the ankle for the operative treatment of pilon fractures, including a straight anterior incision,⁵⁸ a medial incision (according to Schatzker⁹³), and the lateral Böhler approach (according to Herscovici³⁷), or a posterolateral approach.^33,57 Therefore, when planning the fibula incision, the tibial incision should be drawn out so that the placement of the fibula incision is correct.

Posterolateral Approach

1. The patient is placed into the prone position. The posterolateral incision begins directly between the posterolateral border of the fibula and the medial aspect of the Achilles tendon. Care should be taken because the sural neurovascular structures run in the subcutaneous tissues. Full-thickness flaps should be created.

2. Dissection should first be carried out laterally to expose the peroneal fascial. This is released from the lateral border of the fibula, and the peroneal tendons are retracted medially to expose the distal fibular fracture. Care is taken to anatomically reduce the fibula, and a posterior or posterolateral plating technique can be used.

3. The peroneal tendons are then retracted laterally, and the interval between the peroneals and flexor hallucis longus (FHL) is dissected. The peroneal artery lies proximally in the dissection plane. The distal aspect of the posterior tibia is exposed. Often, there is a spike of bone from the posterior malleolar fragment that can serve as a “key” for anatomic reduction. A small or mini-fragment compression plate is then applied to span the fracture in a buttress fashion and secured proximally with cortical screws. If screws are required distally to stabilize the posterior malleolar fragment(s), a short (10-14 mm) unicortical screw should be used to prevent interference with the subsequent reduction of the anterior fragments. Small or mini-fragment locking plates are useful for this purpose (Fig. 36-11).

Figure 36-11 The posterolateral approach is performed with the patient prone. A, The incision is placed between the posteromedial border of the fibula and the lateral border of the Achilles tendon (red lines). B, The peroneal tendons are retracted medially, and the posterior fibula can be reduced and stabilized anatomically. C, The interval between the peroneal tendons and the flexor hallucis longus is developed, and the posterior malleolar fragment can be visualized and reduced anatomically with a buttress plate.

This approach allows excellent visualization of the fibula and posterior tibia to allow fixation. There is a healthy muscular bed underlying the incision from the peroneal and FHL muscle bellies. Care should be taken not to strip the posterior tibia because this can destabilize the posterior tibiofibular ligaments and create syndesmotic instability. The main benefit of posterior tibial plating is anatomic reduction of the posterior tibial fragments, and this creates a stable posterior buttress for future fracture reduction and stabilization from future anterior approaches (Fig. 36-12).

Figure 36-12 Building the distal tibia in a “back to front” fashion. A, Initial lateral radiograph of the injury showing a displaced posterior malleolar fragment with articular comminution. B, An external fixator is placed using ligamentotaxis. Note the posterolateral fragment cannot be reduced indirectly with a fixator. C, The fibula is anatomically reduced, and the posterior malleolar fragment is reduced with a mini-fragment buttress plate. D, Definitive anterior fixation is used to reduce the anterior fragments to a stabilized posterior buttress.

Anteromedial Approach

1. The anteromedial approach⁹¹ begins at the level of the distal shaft of the tibia, just lateral to the anterior crest and continues distally, staying medial to the anterior tibial tendon. As it crosses the ankle, it sweeps along the inferior portion of the medial malleolus. The skin should be taken together with the subcutaneous tissue and the periosteum in a full-thickness flap to prevent separation of the medial skin from its periosteal blood supply.