Fractures of the tibial plafond are usually treated by ORIF by plate and screws, If the patient is seen within the first 6 hours he is admitted to OR but if he comes later with a swollen ankle we prefer to wait for about 10 days untill skin condition improves. Ex Fix is reserved for open fractures. We don not do primary arthrodesis except when there is lost bone and this is usually in open # after ex fix

Thank you Wael, I absolutely agree with your treatment concept. What I am trying to find out is, whether there are country or area specific differences. Would you think that this will be done in the way you described all over Egypt?

dear dr Hagen

thanks from you by interesting question.

in our department in almost all case of pilon s fracture we use 2 stage fixation. in stage 1 fibular ORIF is done. by this fixation anatomical reduction in tibia in almost all case is done. furthermore external fixation for tibia is done at the same stage. this approach can prevent the fracture blister infection and skin necrosis and its not an urgent surgery. before and after operation we encourage the patient to elevate her leg to decrease the swelling. time of surgery is depended on patient condition and decrease swelling. at the 2nd stage we change fixator to ORIF by anatomical plate and anatomical reduction even in articular element.

I am practicing orthopedic surgery in 2 locations, one of them is a general hospital and the other is a university hospital and I I can say the treatment concepts are the same 

'Span - scan - plan' summarises the treatment of a severe pilon fracture.

Span

Soft tissues settle much better in a temporary ankle spanning external fixator than in a plaster cast, and this helps maintain length.  This is combined with the initial wound debridement if the patient has an open fracture.  I try to encourage all my colleagues to get a patient into a fixator within 24 hours of the injury.  Access to theatres in the evening in our hospital is very poor - almost always this is done on the trauma list the next day.  It makes it much easier to watch the soft tissues once the leg is 'safe' in a fixator, and it means that the CT scan is performed on a fracture that is provisionally reduced.

Scan

CT scan determines the surgical approach for articular reduction, and surgical planning - 1 incision / 2 incisions.  For me, the most important CT image is the axial cut just above the ankle joint.  Often there is an anteromedial or anterolateral fracture line that can be opened to give access to central depression fragments.

Plan

There is no one correct way to fix a pilon fracture because the decision depends on multiple factors, including the patient, their soft tissues, the amount of metaphyseal comminution, the length of proximal fracture extension, associated injuries.....etc.

In general, my preference is usually not to fix the fibula.  If there is a lot of comminution of the distal tibial metaphysis, it means that you are left with a big hole to fill - whereas if the tibia and fibula both heal a little short, but congruent with each other, that is probably better.

Where the soft tissues are in good condition by about 10 days post injury, I will fix the fracture with lag screws and several small buttress plates (2.7 or 3.5mm 1/3 tubular), or occasionally precontoured distal tibia plates, anterior or medial, depending on fracture configuration.  If the fracture is relatively simple, a MIPO technique might be possible, but not at the expense of doing a good fixation!

Sometimes a circular frame is a better choice, for example if the soft tissues are poor, fracture was open, patient is high risk (diabetic, peripheral vascular disease), or there is a lot of metaphyseal comminution.

Practice varies a lot across the UK - some cities plate almost all pilon fractures, others put almost all in a circular frame.  It's always a source of lively debate at round table trauma meetings!

I like the Span,Scan ,Plan approach  of Stephene for sever Pilon Fx,and that is the mainstay of Pilon Fx treatment in my home country.If I can achieve fibula lenght with Ex Fix ,I would deny another incision on lateral side. 

I apply an Ilizarov circular fixator and span the ankle using ligamentotaxis; at 6 weeks I reduce this to a tibial frame with olive wire fixation and compression of the distal fragments (+/- percutaneous screws rarely) and commence weightbearing. frame removal occurs at 12 weeks.

Assessment of soft tissues condition, early treatment within first 6 hours, and using minimal invasive technique of fixation is very important because of several complications such as nonunion, malunion, implant failure, and wound complications. Infection may have the most devasting effect.

Mr. Stephen A Milner  completely described pilon fracture from all aspects. I just want to express my agreement with him regarding fibula fixation which may be troublesome in many cases as he explained. We used to apply temporary skeletal traction by a calcaneal pin before, but now we use spaning Ex Fix .