One of the most important factors in choosing the appropriate surgical approach for a given injury is the location of the fracture lines and the associated comminution.9,10 The most frequently used approaches for articular injuries are the anterolateral and the anteromedial. Multiple approaches have been suggested, but there is no consensus regarding the optimal treatment for these injuries and no long-term outcome measures that define the results of either the injury or the treatment. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. Distal tibial physeal fractures can be described using a number of classification systems. 30 … The classification for distal femur fractures can be seen in Figure 34.1 and is defined as follows 8: This can be a stage 2 of a Weber C fracture. The three-dimensional animations with radiographic correlation presented in this article may aid understanding of this classification system and ultimately enable radiologists to translate radiographic findings into a traumatic mechanism. Some important principles include placement of all pins remote from any anticipated surgical incisions, avoidance of pin placements into the talus if any anterior exposure is planned, and pin placement into subcutaneous locations to minimize pin-site irritation and drainage. There are other, often more subtle, fractures about the knee. According to the 10th edition of “Campbell Orthopedic Surgery”, the term tibial plafond fracture, pilon fracture, and distal tibial explosion fracture have all been used to describe intra-articular fractures of the distal tibia. The talus should be accurately reduced and centered in line with the central axis of the tibia (Fig. Anatomy of pilon fractures of the distal tibia. 6-27), fibular head, and tibial tuberosity (see Fig. Plain radiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. Conventional radiography remains the primary diagnostic imaging modality for assessing fractures and dislocations. Limb exsanguination and tourniquet application assist with visualization within a bloodless field. extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle) plays an important role in transitional fractures (Tillaux, Triplane) posterior inferior tibiofibular ligament (PITFL) Inability to bear weight for 4 steps both immediately and in the emergency department. Beebe MJ, Auston DA, Quade JH, Serrano-Riera R, Shah AR, Watson DT, et al. However, the prerequisites of such an approach include the following: A complete understanding of the injury, the fracture pattern, and the associated articular involvement, Confidence that a thorough debridement of the open injury has been done in a timely manner, An understanding of the techniques through which the surgeon can reduce and internally fix portions of the injury with “minimally invasive” methods, A well-rested and appropriate surgical team. Classification of femoral shaft fractures is straightforward. An understanding of the ligamentous attachments at the ankle joint is particularly useful when considering displacement patterns and planes of safe surgical dissection. The initial radiographic evaluation consists of standard ankle and tibial radiographs. Because of the complexity of these injuries, multiple surgical approaches are frequently required. Any change in either the length or the rotation of the distal fibula will be reflected in the anterolateral and posterolateral segments of the distal tibia. After identification of all the fracture fragments on the CT scan, the findings can be correlated with the findings of the plain radiographs obtained after length has been reestablished. The superficial peroneal nerve is purely sensory and travels from posterior to anterior, crossing the anterolateral surgical incision (Fig. ... Pediatric Radiology, Vol. Equipment Used for Open Reduction and Internal Fixation of Pilon Fractures, Medium femoral distractor (used to distract between the talus and midshaft of the tibia to enable visualization of the distal tibial articular surface), Kirschner wires (K-wires) of varying sizes, 2.5-mm terminally threaded pins as joysticks, Small-fragment screws (2.7 and 3.5 mm; with long lengths, e.g., 60 to 80 mm), Mini-fragment screws (2.0 and 2.4 mm; with long lengths, e.g., 40 mm), Headlight to visualize the articular surface, Multiple plates consistent with the screws and preoperatively planned bone tamps, Allograft bone chips (as necessary) versus a bone graft substitute. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. The differential diagnosis mostly depends on the review of the conventional radiographs and the age of the patient. The surgical approach for fixation of the fibula should be in a posterolateral location, posterior to the palpable back border of the fibula. Long-term results of pilon fractures. AJR Am J Roentgenol . 1996 May. Fractures of the distal tibia are among the most difficult injuries facing the orthopaedic traumatologist. A simplified AO/OTA classification differentiates between two-part fractures (type A), wedge fractures with butterfly fragments of varying size and possible comminution (type B), and complex fracture, including segmental and multipart comminuted fractures without contact between the proximal and distal diaphyseal segments (type C). 34.3). 2005;87 (5): 692-7. The Rüedi and Allgöwer classification of pilon fractures. If open reduction is anticipated, reestablishment of the length of the tibia and fibula is necessary. 34.7). MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? Petit P, Panuel M, Faure F. Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination. Stress fracture of the distal tibia post ORIF. Typically high energy injuries and occur as a result of an axial loading which drives the talus into the tibial plafond. Fatigue fractures (also known as overuse fractures) are a type of stress fracture due to abnormal stresses on normal bone. 10.1055/b-0036-129630 Ankle Fractures and Dislocations Cory Collinge, Derek Dombroski, and Keith Heier The ankle is the most commonly injured weight-bearing joint of the body,1 and most orthopedic surgeons routinely treat these injuries. 2. {"url":"/signup-modal-props.json?lang=us\u0026email="}. The gastrocnemius and soleus muscles have a common tendinous insertion at the level of the ankle joint, and their tendon sheath requires protection in any posterior approaches. Often, even when the fibula is “out to length,” the medial column is still short. Posterior malleolus fractures are fractures of the posterior segment of the tibial plafond and a common occurrence in the setting of bimalleolar or trimalleolar ankle fractures. (1993) ISBN:0387558373. Finally, an additional pin is placed into the anteromedial face of the tibia to prevent rotation around the proximal pin. Similarly, in displaced complete articular fractures (type 43C), closed methods are ineffective in accurately reducing the articular segments. 6 Fractures in each type are then classified on the basis of fracture comminution into one of three groups, each of which can be further subdivided into three subgroups based upon other fracture … Open fractures require careful preoperative planning about the placement of incisions for the surgical extension of open wounds to enable an adequate debridement. Introduction. Conversely, large implants are rarely needed to support cortical bone that has failed in tension if the compression failure side has been supported. 2007;127 (1): 55-60. Lower Extremity Danis – Weber Classification of Ankle Fractures; Classification: Description: Notes: Type A: Fracture distal to ankle joint: Often avulsion. Fracture of metaphysis, epiphysis and epiphyseal line were noted separately for distal tibia. tibia . 6. It is worth noting that fractures may be invisible on one projection. After placement of the proximal 5-mm bicortical tibial pin (perpendicular to the anteromedial face of the tibia) and the 5-mm calcaneal tuberosity pin (parallel to the distal tibial coronal plane articular surface), length and coronal alignment can be obtained. The use of a tourniquet in articular fractures of the distal tibia is not optional and is preferred in most circumstances. distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus; articulates with the talus and fibula laterally via the fibula notch; Vascular anatomy . Several factors contribute to increasing complexity in these injuries and include proximal fracture extensions, multiple articular fragments, impacted segments, bone loss, and osteopenia. [Medline] . The articulating distractor-compressor clamp can be used to regain length with a standard external fixator. In clinical practice however frequently eponyms like Colles' and Barton's are used. Tertius fracture - seen on AP view (red arrow) and on lateral view (yellow arrow). These fragments typically retain connections with portions of the deltoid (medial fragment or malleolar segment), anterior tibiofibular (Chaput segment), and posterior tibiofibular ligaments (Volkmann′s segment). Video 34.3 Ankle-Spanning External Fixator. An open distal tibia fracture with a relatively simple articular injury but with a complex distal fibular fracture. There are many ways to describe distal radial fractures and there are several classification systems. The approach facilitates accurate articular reduction combined with submuscular and subcutaneous plate applications spanning the metaphyseal comminution. This is directly related to the special geometry of these fractures that have important transverse components. The peroneal muscles (longus and brevis) occupy the lateral compartment of the leg, have a distal muscle belly posteriorly, and are firmly attached at the distal fibula by the peroneal sheath. Frequently adopted is the one proposed by Ruedi and Allgower 5: type I: articular fracture with minimal or no displacement. Although some flexibility in treatment is important in these injuries, these tenets remain a good starting point during the formulation of an operative strategy. The AO Foundation/Orthopaedic Trauma Association (AO/OTA) fracture classification was published as a compendium to the Journal of Orthopaedic Trauma (JOT) in 1996. Nonoperative treatment of distal tibial fractures is recommended only for truly nondisplaced fractures or fractures in patients that have an absolute contraindication for surgical management. 166(5):1203-6. Group: Tibia, distal end segment, complete, multifragmentary articular and metaphyseal fracture 43C3 Qualifications are optional and applied to the fracture code where the asterisk is located as a lower-case letter within rounded brackets. The FHL has a very distal muscle belly, and its identification is especially useful in the posterolateral approach to the distal tibia. Presentation. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification incorporates all fractures of the distal tibia, including extra-articular injuries of the distal tibial metaphysis (Fig. Similar trends were noted when evaluating intraobserver reliability. It has a role in determining treatment. Direct medial approaches to the distal tibia, because of the subcutaneous nature of the bone in that location, are associated with an unacceptably high rate of soft tissue complications and should be avoided; they are not discussed in this chapter. These injuries are frequently open, especially on the medial side where the distal tibia is in a subcutaneous location. Stabilization of either or both the midfoot and the forefoot is still required to maintain the foot in neutral dorsiflexion. Topliss CJ, Jackson M, Atkins RM. The value of CT scans in assisting with preoperative planning and fracture understanding has been well demonstrated.1 Similarly, contralateral ankle radiographs are frequently helpful in understanding the unique morphological variations in the distal tibial anatomy and assist with pre-operative planning. The anterior tibial compartment contains, from medial to lateral, the tibialis anterior, the extensor hallucis longus (EHL), the extensor digitorum communis (EDC), and the peroneus tertius. There is a Tillaux fracture due to avulsion of the anterolateral part of the distal tibia by the anterior syndesmosis. distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus; articulates with the talus and fibula laterally via the fibula notch; Vascular anatomy . Articular incongruity and talar subluxation are poorly tolerated at the tibiotalar joint. Standard tibial plateau fractures involve cortical interruption or depression or displacement of the articular surfaces of the proximal tibia without concomitant significant injury to the capsule or ligaments of the knee (,1). : marked comminution as well and tumor-like lesions into a definitive pattern ” the collateral! 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