1、11/2/2022 Definition：Pilon fracture refers to distal tibia fractures which involve tibia-astragalus articular surface.Pilon fracture havent got clear definition yet,it usually refers to third distal tibia fractures spread from the joint.The distal tibial articular surface always serious shattered,bo
2、ne defect and remote cancellous bone compression.It usually Associated with the lower part of fibula fractures(about 75%85%)and serious soft tissue injury.11/2/202211/2/2022 Definition origin:In 1911,the French radiologist Destotti firstly put forward the word-tibial pilon“.He described the shape of
3、 distal tibia as the pharmacists pestle(pilon).The distal tibial articular surface is also looks like ceiling;In 1950,bonin called it“tibial platfond”,so pilon fracture can be called Platfond fracture.11/2/202211/2/2022 Injure mechanism:Tibial Pilon fractures occur most often in the fall,crash arres
4、t,skiing or stumbling before the fall.Axial tibial violence or torsion violence of lower extremity are the main reason for distal tibial articular surface fractures.Two different mechanisms of injury leading to different prognosis of Pilon fracture.The position of ankle joint when it hurts and the t
5、ype of fracture are closely related.11/2/202211/2/2022 Fracture characteristic:It is a highly unstable fracture,and have severe articular cartilage damage.Treatment is difficult,with many complications,high disability rate,and it is one of the most challenging orthopaedic problems.11/2/202211/2/2022
6、 Fracture classify:The main purpose of fracture classification is to guide treatment and prompt prognosis.In 1969 Ruedi and Augower divided Pilon fracture into 3 types according to the articular surface and metaphyseal displacement and crushing degree,the meaning of this type lies in emphasizing the
7、 articular surface damage.11/2/2022 Ruedi-Allgower分类系统 型:经关节面的胫骨远端骨折，较小的移位;型:明显的关节面移位而粉碎程度较小;型:关节面粉碎移位及粉碎程度较严重。这种分型临床常用。11/2/2022The Ruedi-Allgower classification system:Type one:The articular surface fractures of distal tibia,a little displacement;Type two:The obvious articular surface shift and cr
8、ush lesser degree;Type three:Articular surface crushing shift and the degree is serious.This type of commonly used clinical.11/2/202211/2/2022 Diagnosis:According to the medical history,symptoms,signs,combined with X,CT imagings,diagnosis is not difficult,pay attention to vascular,nerve,soft tissue
9、injury,The inside of tibial,anterior open and potential open injury are common,carefully check the body.Pay attention not to miss the other part injury of the body(spinal fractures,upper fibula fracture etc).11/2/2022（1）非手术治疗：适应于型无移位骨折、全身情况较差不能耐受手术者、以及为延期手术做准备的治疗。主要有手法复位石膏外固定、跟骨牵引等。11/2/2022(1)Non o
10、peration treatment:Adapted to the type I fractures without displacement,poor general condition which can not tolerate operation,as well as the treatment for the deferred operation.Mainly with manipulative reduction and plaster external fixation,calcaneal traction,closed pinning fixation,etc.11/2/202
11、2（2）手术治疗：手术指征：、型开放性骨折，骨折明显移位或嵌插、缺损、伴有神经血管损伤、轴向对线不良、关节面骨折移位大于2mm者，均需积极行手术治疗。11/2/2022 Operation treatment:Operation indications:Tpre II,type III open fractures,fracture was obviously displaced or impacted,defect,accompanied by the nerve and vascular injury,the axial malalignment,articular surface fra
12、cture displacement is greater than 2mm,these all should be actively treated with surgical operation.11/2/2022 手术原则：低能量损伤的pilon骨折积极行切开复位内固定术（ORIF）；高能量损伤者，采取有限内固定和外固定结合的治疗手段。目前主张“生物学”原则：强调细致的软组织暴露，骨折块的有限剥离，间接复位，稳定固定后早期活动和晚期负重等.治疗目的可归纳为“3P”，即保护骨与软组织活力、进行关节面的解剖复位、提供满足踝关节早期活动的固定。11/2/2022 Operation princ
13、iple:Low energy damage of Pilon fractures treated with open reduction and internal fixation of positive(ORIF);high energy injury,take limited internal fixation and external fixation combined treatment.Currently advocated“biology”principle:emphasizing meticulous soft tissue exposure,fracture block fi
14、nite strip,indirect reduction,do early exercise after stable fixation and late weight bearing,etc.Treatment goals can be summarized as“3P”,the protection of bone and soft tissue viability(preserve),anatomical reduction of the articular surface(perform),provide fixations which can satisfy early motio
15、n of the ankle joint(provide).11/2/2022 手术时机：1、开放性骨折就诊时间早或出现筋膜间室综合征的患者，均应行急诊手术处理。对于污染严重的（先清创）、就诊时间晚、肿胀严重、软组织条件差的开放性骨折主张先行跟骨牵引、石膏托固定、或超关节外固定架临时固定等治疗，待肿胀消退，水泡愈合后行二期处理。2、对于闭合性骨折的手术时机，目前还存在较大的争议，大多数人倾向于认为除软组织条件差的闭合性骨折需行延期手术外，一般应于伤后8-10小时之内，肢体肿胀不甚严重，无明显水泡形成之前急诊手术为妥，有利于骨折复位。张力较高及皮肤缺损者，可留待创面行二期处理。这个应该放在开放性
16、骨折后面11/2/2022 Operation time:Patient of open fractures to see a doctor early or turn up compartment syndrome,urgent operation treatment is necessary.For the serious pollution(first debridement),treatment time of late,severe soft tissue swelling,poor conditions of open fracture of calcaneus traction
17、that go ahead of the rest,plaster support,or over articular external fixator for treatment of temporary fixed,after swelling,blisters healed,do the secondary period of treatment.For a closed fracture of the operation opportunity,at present still exists controversy,I agree with that,in addition to po
18、or conditions in the closed fractures should do delayed operation,generally most fracture should do urgent surgry in 8-10 hours after injury when the swelling of a limb is not serious and no blister formation.This facilitates fracture reset.Higher tension and skin defect wound,may be left for second
19、ary treatment.11/2/2022 手术方法：型：有时为了避免非手术治疗可能发生的骨折移位缩短外固定的时间，采用有限切开简单内固定加石膏外固定,闭合复位后经皮空心螺钉固定术,微创经皮钢板接骨术(MIPPO技术)。11/2/2022 Operation method:Type I:sometimes in order to avoid non operation treatment of possible displacement of fracture and shorten the time of external fixation,we choose limited open
20、simple internal fixation combined with external fixation of plaster.After closed reduction and percutaneous hollow screw fixation,minimally invasive percutaneous plate osteosynthesis(MIPPO technology);11/2/2022 型：关节面虽有移位，但并未粉碎和压缩，以有限切开复位内固定为宜。近年来有主张关节镜结合环形外固定架的治疗和关节镜辅助下复位经皮螺钉内固定术。11/2/2022 Type II:T
21、he articular surface displaced,but not crushed and compressed,limited open reduction and internal fixation is appropriate.In recent years,someone have advocated the arthroscopy combined with circular external fixation;Arthroscopic assisted reduction and percutaneous screw fixation have also been use
22、d.11/2/2022 型：闭合性的高度不稳定骨折，关节面严重粉碎者，行经典的切开复位内固定术加植骨术。严重粉碎已无解剖复位可能的高能量损伤、大块骨缺损、严重软组织损伤、开放性骨折的Gustilo、型患者行有限的切开复位内固定结合外固定支架是较好的选择。也有主张行分期重建内固定的方法，先固定腓骨，同时使用外固定支架保持肢体的长度和力线，经过1021d的中间期，使软组织的条件得以充分改善以减少术后软组织的并发症；再对胫骨远端的关节面进行标准的切开复位内固定。11/2/2022 Type III:Closed highly unstable fractures,comminuted articul
23、ar surface,choose classic open reduction with internal fixation and bone graft.Severe comminution have no anatomical reduction potential of high energy injury,massive bone defects,severe soft tissue injury,open fracture of the Gustilo II,type III were treated with limited internal fixation combined
24、with external fixation is a good choice.Somebody claims reconstruction methods of fixation by stages,fix fibula firstly,at the same time using external fixation to maintain limb length and line of force,after 10-21d intermediate period,so that the soft tissue conditions can be fully improved to redu
25、ce postoperative soft tissue complications;then,the standard open reduction and internal fixation are used in the distal tibial articular surface.11/2/2022 关节融合术和关节置换术：由于Pilon 骨折的患者不是都能达到完全的解剖复位，即使可以解剖复位，由于骨折后关节软骨下骨发生坏死、塌陷变化，也就不可避免创伤性关节炎的发生。因而踝关节融合术、关节置换术的时机选择,应根据具体情况而定。一般宜在伤后12 年内根据症状、体征、X 线表现及患者要求
26、行融合术或置换术。11/2/2022 Arthrodesis and ankle joint replacement:Because not all of Pilon fracture patients can achieve complete anatomic reduction,even can achieve anatomic reduction,due to articular subchondral bone necrosis and collapse after fracture,it is inevitable that the occurrence of traumatic o
27、steoarthritis.Thus the arthrodesis and replacement of the ankle joint timing,should be based on the specific circumstances of the case.Generally after injury in 1-2 years according to the symptoms,signs,X ray performance and patients require fusion and replacement surgery.11/2/2022 总之：从文献报道的有关Pilon
28、骨折治疗的临床研究来看,制定合理而完善的术前计划、有限内固定结合外固定治疗以及根据软组织损伤情况分期治疗,降低了软组织损伤导致的并发症发生率，已显示出其明显的优越性。同时，治疗过程中踝关节早期功能锻炼，避免过长时间的外固定，能最大限度地减少针道感染、关节僵硬等并发症。11/2/2022 In conclusion,from the literature reports about Pilon clinical study on treatment of view,establish reasonable and perfect preoperative planning,limited int
29、ernal fixation combined with external fixation in the treatment of soft tissue injury and according to the staging of treatment,have reduced the soft tissue damage which leads to the complication rate,and obvious advantages have been proved.At the same time,during the treatment of ankle joint and ea
30、rly functional exercise,avoid prolonged external fixation,can minimize the pin tract infection,joint stiffness and other complications.11/2/2022 切开复位内固定原则：（1）恢复腓骨长度并做内固定;（2）力求解剖复位，重建胫骨远端关节面（关键骨折块、Chaput结节等）;（3）干骺端骨缺损处植骨（支撑关节面、填补空缺、刺激成骨、促进骨折愈合）;（4）胫骨内侧支撑钢板固定，重新连接骨干与干骺端，早期功能锻炼，晚负重。11/2/2022 Open reduc
31、tion and internal fixation principles:(1)restoration of fibular length and internal fixation;(2)achieve anatomical reduction,reconstruction of distal tibial articular surface(critical fracture block,Chaput nodule etc.);(3)bone graft of metaphyseal bone defect(supporting the joint surface,filling the
32、 vacancy,stimulation of osteogenesis,accelerate fracture healing);(4)the tibial medial buttress plate fixation,reconnect the backbone and the metaphysis,early functional exercise,late weight bearing.11/2/2022 治疗中的常见问题及并发症的防治：Pilon骨折，尤其是高能量损伤的Pilon骨折，并发症的发生率很高，处理好并发症的问题可以说是治疗Pilon骨折成败的关键。注意预防皮肤坏死、感染、
33、创伤性关节炎、关节僵硬、畸形愈合、骨不愈合、延迟愈合。有报道用带关节的外固定架治疗高能量损伤的pilon骨折疗效满意，避免了关节僵硬。中西医结合防治并发症。11/2/2022 Common problems in the treatment and prevention of complications:Pilon fracture,especially high energy injury Pilon fracture,have high incidence of complications,the treatment about complication problems can be s
34、aid to be critical to the success of the treatment of Pilon fracture.Pay attention to the prevention of skin necrosis,infection,traumatic arthritis,joint stiffness,deformity,bone nonunion,delayed healing.There have been reports with articulated external fixator in the treatment of high energy injury Pilon fracture got curative effect satisfaction,it have prevented joint stiffness.Integrated traditional Chinese and Western medicine in the prevention and treatment of complications is a good choose.11/2/202211/2/202211/2/202211/2/202211/2/202211/2/202211/2/202211/2/2022
