The classification system, broken into three categories focuses on the displacement and pattern of the fracture and the integrity of the coracoclavicular ligaments. Currently the tibial pilon fractures are classified according to Ruedi Allgower and AO classification system , . The pilon fracture usually has an anterolateral (Chaput) fragment and a posterolateral (Volkmann) fragment. Type 2 open fractures have more extensive soft tissue injury with minimal to moderate crushing, typically with a laceration > 1 cm. Articles and authors. 1) Muller-AO Classification of distal humeral fractures (also called just Muller or AO or OTA) Similar to AO classification of distal radius A- Extra-articular fracture (Supracondylar) Pilon fractures in the distal tibia result from axial forces that can range from low to high energy and produce a spectrum of articular and metaphyseal injuries. A common modern algorithm is to apply a spanning external fixator to maintain length urgently following injury. Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness (Babis et al 1997, Sands et al 1998, Pollak et al 2003). A systemic motor and sensory examination is warranted in addition to documentation of distal pulses. A new CT-based classification from Bristol builds on the work of Tournetta and offers important new insights. Volume 32: Number 1; Supplement, January 2018. "AO" is an initialism for the German "Arbeitsgemeinschaft für Osteosynthesefragen", the predecessor of the AO Foundation. 1a-c). Some surgeons have found that immediate (within a few hours of injury) open reduction, prior to significant swelling, can be performed safely. Type 3A open fractures have adequate soft tissue coverage over the fracture. Thordarson DB. In this group there was always a tibial fragment remaining in the correct relationship to the fibula which could be used to help judge reduction, but failure to recognise and reduce talofibular incongruity led to poor results. In publications, it will be cited as Meinberg E, Agel J, Roberts C, et al. A pilon fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint.Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents. Rüedi-Allgöwer classification and AO/OTA classification for Pilon fractures are widely used until now. Complications after treatment of tibial pilon fractures: prevention and management strategies. OBJECTIVES: To evaluate the interobserver variation for the AO/OTA fracture classification system: region forty-three-pilon fractures. Select specialty. Understanding the soft tissue injury accompanying pilon fractures is of utmost importance for providing optimal treatment while minimizing complications. 2013 Jul. 8 Three types are included in Rüedi-Allgöwer classification, depending on the displacement of articular surface, metaphyseal and injury extent of fractures, which is easy to remember and to evaluate the outcome of pilon fractures. Posterior partial fracture overlap with malleolar fractures with posterior malleolar components (Klammer 2013), and anterior partial fractures were included by Lauge-Hansen (1950) iin his classification of malleolar fractures, 43C: complete articular fractures with no connection between the joint surface and diaphysis – most pilon fractures fall into this group, 43C1: no comminution of epiphysis or metaphysis, 43C2: comminution of metaphysis but not epiphysis, 43C3: comminution of epiphysis +/- metaphysis (corresponding roughly to Ruedi-Allgower group III, many pilon fractures are in this category). This classification is arranged in order of increasing severity according to the complexities of the fracture, difficulty of treatment, and worsening prognosis. New research was undertaken to determine the best way to manage higher energy fractures of the tibial plafond in response to the higher rates of infection. Abstract Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. Anterolateral exposures for pilon fractures risk injury to the superficial peroneal nerve. The compendium is branded as the AO/OTA or OTA/AO Fracture and Dislocation Classification Compendium. . Protocols developed to enhance soft tissue recovery prior to definitive operative fracture fixation, including greater waiting time for such recovery, became the mainstay. 4. A diagram summarising fracture alignments is provided, which implies very few fracture lines in intermediate positions between the coronal and sagittal families - it would be valuable to reproduce this in a different data set. When the fibula was intact, 58% of fractures were partial articular type B. The AO Spine Classification Group reached a consensus on a classification that incorporates both fracture morphology and clinical factors relevant for clinical decision making. 27(7):e152-6. Dear Visitor, Your browser is currently not set to accept cookies. Principle 2: Anatomical reconstruction of the articular surface of the tibial plafond is performed after the acute phase of the injury. Principle 1: Length and rotation is restored by ORIF of the fibula. Type A is extra-articular, type B is partially articular, and type C is completely articular. The AO long bone group universal classification of fractures groups distal tibia fractures as 43. The AO long bone group universal classification of fractures groups distal tibia fractures as 43. The superficial peroneal and saphenous nerves are superficial to the fascia. The Müller AO Classification of fractures is a system for classifying bone fractures initially published in 1987 by the AO Foundation as a method of categorizing injuries according to therognosis of the patient's anatomical and functional outcome. Type-III fractures are the most frequent presentation, comprising approximately 25% to 71% of all pilon fractures. Topliss et al (2005) re-examined the anatomy of pilon fractures based on plain radiography and CT. Retrieved Besides lectures and video presentations, patient cases will be discussed. Leg compartment syndrome should be diagnosed based on clinical examination and confirmed if necessary with compartment pressures. The authors describe how this influences surgical approach but the data do not clarify this and the classification may need some further development to make a distinct contribution to decision making. Type 3 injuries portend the worst prognosis as a consequence of articular comminution and metaphyseal impaction. Principle 4: Buttressing of the tibial metaphysis is then required while connecting the articular block to the diaphysis. The distal tibia is designated as #43 (4 = tibia, 3 = distal segment). Management selection. alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2) Techniques: External fixation. This relatively rare injury (< 10% of lower extremity fractures) usually occurs in adults (aged 30s to 40s) owing to a fall from height or a motor vehicle crash [ 6 ]. Case description. METHODS: One senior attending, two fellows (one trauma, one foot and ankle), one junior orthopaedic resident, and one experienced research coordinator independently classified eighty-four sets of radiographs. Four observers evaluated computed tomography images of 35 cases with pilon fractures according to the classifications of Rüedi and Allgöwer, AO/OTA, Topliss, and Tang, and recommended a surgical treatment plan, including the surgical approach, implant position, and need for … Fracture classification. Ruedi-Allgower type 1 fractures are minimally displaced cleavage fractures, in contrast to type 2 injuries, which are displaced. Thordarson DB. The concave tibial plafond provides ~ 40% more posterior than anterior coverage. Pilon (tibial plafond) fractures - Ruedi and Allgower classification. Open fractures with vascular injury requiring repair along with extensive soft tissue compromise are considered type 3C. Arbeitsgemeinschaft für Osteosynthesefragen/OTA pilon fracture classification system is shown. We help you diagnose your Distal tibia case and provide detailed descriptions of how to manage this and hundreds of other pathologies In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Surgical timing and type of fixation utilized is largely dictated by the condition of the soft tissues. Luk (2013) compared pilon fracture types in patients with and without an intact fibula. There are subtypes of each classification based on increasing complexity of the articular and metaphyseal components ( Fig. Comminution, which frequently occurs with high-energy pilon fractures, is most typically located in the anterolateral and central regions of the plafond. Moderate interobserver reliability makes the AO/OTA system reliable for classifying pilon fractures (Swiontkowski et al 1997). Pilon fractures can occur from both low- and high-energy mechanisms. A severely traumatized soft tissue envelope accompanies the higher energy pilon fractures. Destot coined the term pilon, as he thought that the distal tibial metaphysis resembled a pharmacist’s pestle. The tibial pilon fracture is a rare, yet devastating injury. Classification. 19-year-old man ... Day 0. More educational tools. 110.2 ) … Impaction most commonly occurs at the dome between the 3 main fracture fragments. The compendium is branded as the AO/OTA or OTA/AO Fracture and Dislocation Classification Compendium. In publications, it will be cited as Meinberg E, Agel J, Roberts C, et al. In the vast majority of pilon fractures, the fracture lines propagate from the fibular incisura laterally in the shape of a Y to exit anterior and posterior to the medial malleolus. According to the Fernandez classification, 26 patients (76%) had type 5 fractures, and 8 patients (24%) had type 3 fractures. The results of the classic study from the Swiss AO group could not, however, be reproduced by all surgeons. When the ankle is dorsiflexed at the time of injury, pilon fracture patterns involve the anterior articular surface of the tibial plafond. Explore AO Trauma's varied teaching and learning materials to enhance your expertise. AO/OTA Fracture and Dislocation Classification Long-bone Fractures 41B Partial articular 41B1 Split 41B2 Depression 41B3 Split depression 41C Complete articular 41C1 Simple articular, simple metaphyseal 41C2 Simple articular, wedge, or multifragmentary metaphyseal 41C3 Fragmentary or multifragmentary metaphyseal 43A Extraarticular 43A1 Simple The talus has the opposite geometry of the tibial plafond and therefore serves as a perfect template for assessing articular reduction of the distal tibia. 27(7):e152-6. The most common fracture pattern occurs with the ankle in dorsiflexion (i.e., the foot on the brake pedal during a motor vehicle accident). The tendinous and neurovascular structures are covered proximally by the investing fascia of the anterior compartment and distally by the extensor retinaculum. There may be some benefits to this technique with possibly less swelling and stiffness. 43A: extra-articular – most would not recognise these as pilon fractures, although in some series non-articular fractures are included and it can be difficult to tell how many were articular 2. Matthew Tomlinson. Can be combined with subtypes of A or B. AO Spine Thoracolumbar Classification System Disclaimer: 1. Surgical indications for operative fixation of pilon fractures include open injuries, 2 mm of articular displacement, talar subluxation, or malalignment greater than 5 degrees. Open pilon fracture with extensive soft tissue injury and a severe crush component are graded as type 3. Figures. Fracture and Dislocation Classification Compendium–2018, Journal of Orthopaedic Trauma. Once the swelling has peaked and regressed 1-3 weeks after injury, open reduction of the tibia (and fibula) can be performed with removal of the temporary external fixator. Complications after treatment of tibial pilon fractures: prevention and management strategies. Although many pilon fractures are open injuries, closed fractures have significant soft tissue compromise as well. (OBQ12.156) A 36-year-old male sustains an open segmental tibia fracture associated with an overlying 8 cm soft tissue avulsion that requires skin grafting for soft tissue coverage. Principle 3: Metaphyseal bone defects are bone grafted to buttress the articular surface. The AO/OTA classification system provides a comprehensive description of distal tibial fractures. Reports describing ORIF of tibial pilon fractures revealed a concerning complication rate with higher energy pilon fractures, including wound problems, deep infection, nonunion, and malunion (McFerran et al 1992, Teeny and Wiss 1993). . Fracture and Dislocation Classification Compendium–2018, Journal of Orthopaedic Trauma. Dr Daniel J Bell ◉ and Dr Yuranga Weerakkody ◉ et al. 1-10% of LE fx’s . 2000 Jul-Aug. 8 (4):253-65. Data Trace is the publisher of Wheeless' Textbook of Orthopaedics Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management.. Data Trace Publishing Company 110 West Rd., Suite 227 Towson, MD 21204 Telephone: 410.494.4994 Pilon fractures, or fractures of the tibial plafond, range from low- to high-energy axial-loading injuries. Limited ORIF to improve articular reductions without formal operative exposures was then employed to supplement external fixation strategies. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. 2013 Jul. With this type of injury, the other bone in the lower leg, the fibula, is frequently broken as well. The tendons of the anterior compartment, the dorsalis pedis artery, and the superficial and deep peroneal nerves can be encountered with anterior exposures at the level of the ankle joint. The most widely used classification systems for pilon fractures are Ruedi-Allgower and AO (Arbeitsgemeinschaft für Osteosynthesefragen) , but concern has been raised over the accuracy and reproducibility of these 2 classifications (7, 8), which are X-ray based. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. Classification systems have been developed to stratify both severity of fracture pattern and soft tissue injury. Volume 32: Number 1; Supplement, January 2018. 20-25% are open . Classification of distal tibial fractures AO Classification. In: OrthopaedicsOne - The Orthopaedic Knowledge Network. The AO Spine classification of thoracolumbar injuries is one of the more commonly used thoracolumbar spinal fracture classification systems and aims to simplify and universalise the process of classifying spinal injuries and improve interobserver and intraobserver reliability 3.. These classifications are less reproducible and do not provide necessary information for proper surgical planning. Axial CT shows fracture lines dividing the plafond into 3 major fragments: Anterolateral, posterior, and medial. There simply is not a lot of soft tissue around the distal tibia, as compared to more proximal parts of the leg. Traditional classifications of Pilon fractures, either Ruedi-Allgower classificationor AO/OTA classification, are unable to describe all types and complexities of Pilon fractures and have limited contribution to … To view this page please enable your cookie setting. Thordarson DB. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Soft tissue injury has been standardized using the method of Tscherne for closed fractures and the Gustilo-Anderson classification for open injuries. There is no muscle tissue to “cushion” or protect the bone if skin is injured. Insert figures illustrating the classification. Module. In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Arbeitsgemeinschaft für Osteosynthesefragen/OTA pilon fracture classification system is shown. Pilon fractures treated with a cast have led to poorer outcomes than those managed operatively. Type A fractures are extraarticular distal tibial fractures, which are subdivided into groups A1, A2, and A3, based on the amount of metaphyseal comminution. Central articular (implosion) injury is the result of an axial load on the foot in neutral position. In addition to the classification of Rüedi and Allgöwer, the classification of pilon fractures has been carried out using the AO classification. The paper should be read in detail - important points include: Topliss compared the reproducibility of their grouping with division into AO "B" and "C" groups. Learn more. More recently, the AO/OTA classification of pilon fractures has been utilized. ... posterior malleolar fracture.The standard AO classification of ankle fractures is adapted from that of Danis. The operative principles described by the AO group for operating pilon fractures serves as a working paradigm for ORIF of these injuries. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. Code fractures and dislocations with the AO/OTA Fracture and Dislocation Classification 2018 for adults and pediatrics. These are considered to represent 1-10% of all lower limb fractures 6. AO Surgery Reference is a resource for the management of fractures, based on current clinical principles, practices and available evidence. Day 0. Indications for closed reduction and cast treatment of pilon fractures are limited. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. Get started now. Two main classifications are used, which use different criteria for grouping. The 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium for adults and children addresses the many suggestions to improve the application of the system, as well as add recently published and validated classifications. The AO classification of clavicular fractures along with the Neer classification system is one of the more frequently used classification systems when assessing distal clavicular fractures.. The dorsalis pedis and deep peroneal nerve are at risk with an anterior exposure. six typical fragments, recognition of which helps plan reconstruction - not all present in any one patient: three main groups of fractures based on the main orientation of the fracture lines: coronal group, typically lower-energy fractures in older patients with a more distal metaphyseal-diaphyseal dissociation and valgus alignment (56%), sagittal group, typically higher-energy fractures in younger patients with a more proximal metaphyseal-diaphyseal dissociation and varus alignment (33%), comminuted fractures of such severity that they could not be assigned to any group (6%), a group of fractures ("lateral disruption fractures") with incongruity of the joint between the lateral malleolus and the lateral talar facet, often with an intact fibula. Figures. No vascular injury is identified. Pilon tibiale fractures with significant joint involvement (AO-classification B2/3 and C2/3) are considered one of the most unfavourable injuries of the lower extremity. 3. An associated fibula fracture is often present in pilon fractures. The aim of this study was to evaluate the pitfalls and strategies of posterior column reduction in the treatment of complex tibial pilon fractures (AO/OTA 43-C3). 27(7):e152-6. Despite the best treatment, patients sustaining high-energy pilon fractures generally do not return to their previous state of general health or function. A pilon fracture is a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint. The Topliss classification was more reproducible, especially in the hands of Topliss herself, although no statistical analysis is provided. What are the goals of treatment? The latest insights in diagnosis, classification and surgical treatment of tibia plateau and pilon fractures are reviewed. The series reported by Ruedi and Allgower described superior outcomes after formal open reduction and internal fixation (ORIF) in their patient population with few major complications.