Pilon Fracture – Causes, Symptoms, Diagnosis, Treatment

Pilon fracture is also known as tibial plafond fracture may be defined as the mechanical rotational or axial force that causes the compression fracture of the lower end of the tibia that is inserted on the talus and forms the talotibial ankle joint most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. Fractures of the distal tibial plafond are also termed pilon fractures that are caused by the high-energy axial compression force of the tibia during the times of driving vehicle, pressuring break as it acts as a pestle, lead vertically into the talus.[rx]

Types of pilon fractures

There are several sorts of pilon fractures counting on the pattern of the break, and there are many classification systems to explain them. Under the Ruedi-Allgower arrangement, healthcare providers categorize pilon fractures because the following types:

• Type I: a kind I pilon fracture is an articular fracture (bone break in or around a joint) with minimal or no bone displacement (the broken bones are still aligned).
• Type II: a kind II pilon fracture happens when the rock bottom of the tibia (known because the articular surface of the bone) is displaced (not aligned), but there are minimal or no fragments (communication). A fracture is when the bone breaks into quite two pieces.
• Type III: a kind III pilon fracture happens when the bone has broken into quite two pieces (comminution) and therefore the ends of the broken bones have driven into one another (impacted fracture). Approximately 25% to 71% of pilon fractures are type III fractures.

There also are sorts of fractures that will apply to any bone break. Your healthcare provider may use one or more of the subsequent terms to explain your pilon fracture:

• Closed or open (compound) fracture: If the fracture doesn’t break open the encompassing skin, it’s called a simple fracture. If the broken bone pierces through the skin, it’s called an open fracture or a compound fracture. Approximately 20% of pilon fractures are open fractures.
• Complete fracture: an entire fracture happens when the bone breaks into two pieces.
• Displaced fractures: A fracture means the broken bones don’t stay aligned like they normally would be.
• Comminuted fracture: A fracture means the bone breaks into quite two pieces.
• Impacted fracture: An fracture happens when the ends of the broken bone are driven into one another .
• Spiral fracture: Spiral fractures happen when the fracture spirals around the bone.

Causes

Causes of Pilon Fracture are following

• The repetitive impact – to the lower limb bone with weight-bearing exercises, occupational work cause microfractures, which consolidate to stress fractures.[rx]
• Heavy impact – The force of a jump or fall down from height can result in a broken ankle. It can happen in foot bone fractures even if you jump from a low height.
• Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
• Sports – High-impact sports such as football cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include, cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
• Car collisions – The sudden, heavy impact of a car accident, bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing types of injuries common in car accidents may cause breaks that require surgical repair.
• Falls from height – Tripping, and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height, sudden landings from the plane in the war field, violent trauma, etc.
• Driving and compressing in break – It is one of the major causes of foot microtrauma for the driver of the car, motorbike, truck, bus, bicycle runner. During the time of driving such kind of vehicle frequently have compress break to maintain the speed of the vehicle. Repeated compression causes, microtrauma, tendon, cartilage, ligament degeneration, and weakness that may lead to injury in the foot.
• Missteps – Sometimes just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
• Unconsciously Toilet Use – It is a very common and day by day increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, especially high comodo using time and lower limb fractures.
• High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
• On a battlefield – with the increasing of technology, nuclear weapons, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
• Have osteoporosis –  a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
• Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing,  Skiing Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.
• Insufficient vitamin D and sunlight – Insufficient vitamin D and sunlight decrease the intestinal absorption of calcium which leads to abnormal regulation of parathyroid hormone (PTH). Vitamin D also works to upregulate the transcription of genes involved in neovascularization in areas of endochondral ossification such as a healing fracture site. Vitamin D deficiency is typically characterized as a serum level of 25-hydroxyvitamin D3 of less than 20 ng/mL and sufficiency is between 20 and 31 ng/mL.[rx]

Symptoms of Pilon Fracture

Symptoms of Pilon Fracture include

• Intense pain, swelling, tenderness, limited range of motion is the first
• May present with pain, swelling, tenderness, hematoma directly over the mid-foot in athletes, and construction workers may present with various pain and swelling over the foot which worsens with exercise and walking.
• Pain with or after normal activity
• Pain that goes away when resting time and then returns when standing, walking, or during activity
• Pinpoint pain at the site of the fracture when touched
• Swelling but no bruising may be present if it becomes microtrauma
• Bruising or discoloration that extends to nearby parts of the foot bones.
• Pain with walking and weight-bearing
• Swelling in the heel area
• Pain may decrease with rest but increases again with activity.
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site after some days.
• Bruising that develops soon after the injury time.
• Inability to walk; it is possible to walk with less severe breaks, and fractures so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the color and appearance of the ankle will look different from the other ankle.
• Bone protruding fracture through the skin is a sign that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
• This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with pain or pain of worsening quality or duration over time.

Diagnosis of Pilon Fracture

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
• Microscopic urine examination test, and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Thromboplastin time and platelet counts will be needed for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test

Imaging

Radiographic evaluation should begin with anteroposterior, lateral, and mortise x-rays views of the ankle. Full-length tibia x-rays should even be obtained to rule out associated fractures and assess the length, alignment, and rotation of the tibia. In patients who had a fall from a height, radiographs of the spine, pelvis, foot and contralateral lower limb could also be indicated to guage for associated injuries, particularly to the spinal column or calcaneus.

Definitive surgical planning for pilon fractures often requires advanced imaging with computerized tomography (CT). the first Ruedi-Allgower classification was supported plain radiographs. Its simplicity and simple use have made it the foremost well-known system for characterizing pilon fractures but has also made it problematic to differentiate more complex patterns and intra-articular fracture lines. the arrival of the CT and 3-dimensional reconstruction has improved the power to discern complex fracture patterns. during a study by during which CT scans provided additional information and altered the operative plan in 82% and 64% of cases, respectively. The timing of CT scan is suggested after the fracture has been adequately reduced and stabilized, most often with an external fixation device.

Treatment of Pilon Fracture

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, play cricket gets into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your leg. If the accident is major you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
• Aggressive wound care – It is very important for patients to reach a safe position with the proper ventilation needed for contaminated wounds. Injured are clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all, that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment needed to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
• Compression – a bandage will limit swelling, edema, and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Put it on again before you are from out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal. Depending on the amount of swelling. pain, edema you may be advised to remove the bandage for good after 48 hours.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing strong stiff-soled shoes to protect the toe and help keep it properly positioned. Use of a postoperative splint, shoe, or boot walker is also helpful.
• Avoid the offending activity – Because fractures result from repetitive stress, the trauma it is important to avoid the activity that led to the fracture more seriously. Crutches or a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury

• Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running and movement – Running and walking may cause further damage, and causes healing delay.
• Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, dexlansoprazole, etc.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
• Teriparatide – Teriparatide may be a recombinant human parathormone (PTH) that stimulates osteoblasts to grow new bone cells when given intermittently. Use in treatment for osteoporosis, osteoarthritis, all kind of fractures has been shown to be successful results, and there are now some scientists to support the use it in treating fractures and nonunions. The medication was administered via daily injections of 20 μg about a month[rx] [rx]

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Surgically treatment depends on the individual fracture characteristics, the size of fractures, the degree of displacement, the location, comminution, the condition of integrity of the soft tissues of the foot, the presence of associate bones, ligament injuries on the foot, comorbidities, and overall functional movement status.[rx]

The treatment of pilon fractures depends on the extent of the injury. This includes the involvement of other bones like the fibula and therefore the talus, involvement of sentimental tissue, and therefore the fracture pattern. Treatment strategies and fixation methods used include internal and external fixation, also as staged approaches, with the aim of reducing the fracture, reconstructing the involved bones, and restoration of articular surface congruence, with minimal insult to soft tissues. Appropriate wound management is vital to scale back the high rate of infectious complications and secondary wound healing problems related to open pilon fractures. Vacuum-assisted wound closure therapy and employing a staged protocol (awaiting soft-tissue recovery before extensive reconstructive efforts) may play a positive role. Surgical indications for operative fixation of pilon fractures include open injuries, 2 mm of articular displacement, talar subluxation, or malalignment greater than 5 degrees. Following AO principles, surgical fixation should provide an anatomically reduced and stable construct, be conducted with gentle soft-tissue handling, and permit for early rehabilitation and mobilization. The general sequence in treating these fractures includes reestablishing length and general axial alignment through fixation of the lateral column, restoration of the articular surface, filling of metaphyseal defects, and reattachment to the diaphysis.

Fibular reduction functions to stop valgus deformity of the ankle and aids in the reduction of the tibial plafond. By restoring the general limb length, the ligamentotaxis effect via the anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament allows indirect reduction of the anterolateral and posterolateral fragments, respectively. One-third of tubular plates with penetration of six cortices on either side combined with lag screws perpendicular to the fracture site is sufficient for fixation. Over lengthening and malreduction can cause varus deformity of the distal tibia and excessive loading of the lateral articular surface. The mortise view of the ankle is employed to verify the anatomical reduction between the distal end of the fibula, lateral tibial metaphysis, and talus. The fibula might not always need to be fixed. If the fibula can’t be restored to its anatomical position or doesn’t aid in tibia reduction, it is often addressed after the pilon component or left to heal without surgical intervention. Recent literature has shown that there’s no difference in final alignment when comparing fibular fractures with versus without fixation in nonrotational pilon injuries. Some studies show patients with ORIF of the fibula had higher nonunion rates, occasionally required plate removal, and had an associated increased incidence of superficial infections.

Three main fracture fragments, medial malleolus, Chaput, and Volkmann are commonly formed as a result of the fracture lines created in pilon injuries. Again, the variability and personality of those fragments are dictated by the position of the foot and cargo applied, bone quality, and the presence of arthritis. In the use of a 2-incision approach, the posterolateral incision provides the surgeon with the power to convert a posh pattern, OTA C-type, into one treated during a simpler manner, B-type. The posterolateral articular fragment is traditionally the more constant piece and may be the source of initial stability and preliminary fixation especially if it remains in continuity with the tibial shaft during a severely comminuted scenario, the posterolateral column should be restored with preliminary reduction and fixation employing a locking unicortical construct through a posterior incision during a staged fashion. This simplifies subsequent fixation from an anterior approach that’s reconstructing the articular segments from a posterior to anterior direction building thereto stable portion. Distraction through an AO distractor or external fixator is often utilized to get the length, alignment, and indirect reduction by means of ligamentotaxis the utilization of a medial talar pin can induce a distraction, plantar flexion, and valgus force. Conversely, a lateral calcaneal pin can induce a distraction, dorsiflexion, and varus force. Preliminary reduction is obtained with the mixture of elevators, osteotomes, and pointed reduction clamps then preliminarily fixed with Kirschner wires (K-wires) or biologic fixation pins. within the event of small reconstructable articular fragments, the impacted articular segment shouldn’t be disrupted but manipulated as an entire by, using the talus as a template. One technique used is levering a good osteotome well above subchondral bone and incorporating some of the spongy metaphyseal bone, to assist in dissipating focus pressures, and dis-impacting the portion together piece. By direct and indirect visualization under fluoroscopy, the reduction is evaluated for restoration of the articular surface with standard ankle views also as oblique views to gauge the anteromedial and lateral corners for reduction. confine mind the inherent 3–5 degree anterior tilt of the distal tibia articular surface when using fluoroscopy, especially on the lateral view. Upon confirmation, K-wires are replaced with definitive screw fixation, and therefore the metaphyseal defect is then crammed with auto- or allograft substitutes ideally with osteoconductive, osteoinductive, and osteogenic properties. If not preliminarily reduced beforehand, the metaphyseal-diaphyseal dissociation is then addressed to realign the anatomical axis of the tibia. Columnar restoration and stability should be obtained with the construct after anatomic articular reduction and fixation. Medial column stability is remitted in varus deformities, conversely lateral column for valgus deformities, the posterior column for plantar flexion, and the anterior column for dorsiflexion injuries. Proper contouring of the plates is vital to avoid residual displacement during plate fixation although this is often irrelevant within the minimally invasive plate osteosynthesis (MIPO) technique.

The quality of the soft tissue within the region can limit the choices of multiple plate fixation. to attenuate further soft tissue injury caused by surgical dissection, minimally invasive techniques like MIPO and intramedullary nailing (IMN) are popularized. Spatial frame application is additionally a useful skill during a surgeon’s armamentarium and may be utilized by those experienced in its principles and facile with the technique. Utilizing the MIPO technique, the extraosseous blood supply of the medial distal tibia is a smaller amount compromised in comparison to open plating. Challenges with this system include plate tendency to drift posteriorly within the sagittal plane upon submuscular placement. Applying a K-wire within the posterior third of the tibia on the lateral view at one-half the plate length can aid in aligning the plate centrally. Though not always warranted, locking plates have demonstrated reliable treatment for patients with osteoporosis or severe comminution and supply further stability against rotational forces. IMN has been shown to possess a task when addressing both extra-articular (AO/OTA-43A1) and straightforward intra-articular (AO/OTA-43C1/C2) fracture patterns

References