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When A Juvenile Patient Presents With A Pilon Fracture
This author provides insights on the surgical treatment of a 15-year-old soccer player, who sustained a Salter–Harris type 4 pilon fracture of the tibia.
A 15-year-old male presented to the emergency department with a Salter–Harris type IV pilon fracture of the right tibia and a distal oblique fracture of the fibula with mild comminution, which he sustained while running and kicking a soccer ball.
The emergency department obtained radiographs and splinted his extremity. The clinical and radiographic exams revealed a closed, significantly displaced Salter–Harris type IV fracture of the distal tibia that may be classified as a pilon fracture. Additionally, within the distal shaft of the right fibula, the radiograph showed a displaced oblique fracture extending from the diaphysis into the metaphysis with some comminution. The fibular fracture did not extend into the distal fibular ephysis. After the exam was complete, we applied a well-padded Jones compression wrap and controlled ankle motion (CAM) boot while he awaited surgical reduction and stabilization. We sent the patient to physical therapy for non-weightbearing gait training.
The patient’s labs consisted of a complete blood cell (CBC) count, Chem-7 panel and 25-hydroxy vitamin D. The labs were unremarkable except his vitamin D was 19.5 ng/mL. This is consistent with deficiency and consistent with decreased bone strength.1,2 We ordered cefazolin 2 gram IV piggyback to be administered before the procedure. In our hospital, we order cefazolin according to body weight. The guidelines we use are as follows: up to 60 kg, 1 g cefazolin; 61 to 199 kg, 2 g; more than 200 kg, 3 g.3,4 We also ordered a sequential compression device for the contralateral extremity for deep vein thrombosis (DVT) prophylaxis.
A Closer Look At The Surgical Technique
We positioned the patient in the supine position and applied a right thigh tourniquet with the patient under general anesthesia and muscle paralysis. With C-arm guidance, we performed closed reduction of the fracture. Note that closed reduction of the distal tibial would not have been successful without muscle paralysis. We obtained a Salter–Harris type IV pilon fracture reduction of the distal tibia with some manipulation difficulty. The C-arm evaluation revealed very good reduction. We could not attain perfect reduction without open reduction, which we discussed and dismissed because the benefit did not justify the risks of further soft tissue envelope trauma beyond this severe fracture.
We placed four half-pins. One of the half-pins was in the medial calcaneus, just anterior to the calcaneal apophysis to avoid injury to the growth plate. The second pin was in the head of the talus, just proximal to the articulation with the navicula. C-arm guidance is needed for proper placement. If there is a question of proper placement of these half-pins, we recommend placing a thin K-wire near the desired pin location and then using C-arm guidance to evaluate for placement and alignment. The K-wire will then act as an excellent alignment guide. Keeping one pin in the calcaneus and the second in the head of the talus provides for an excellent, stable foundation. We do not recommend placing the pin in the neck of the talus as it is very vascular and not as stable as the head of the talus.
Place the remaining two half-pins in the diaphysis of the tibia, ensuring alignment that will facilitate attachment of the external fixator to the medial aspect of the leg. The post-fixation X-ray shows good placement for the external fixation half pins. We then applied the external fixator (TempFix External Fixation System, Biomet) and tightened it to maintain reduction.
We elected to augment the tibia reduction stability by placing two 4.5 mm partially threaded cannulated screws from anterior tibia to posterior tibia. A review of the computed tomography (CT) image reveals why we used the extra percutaneous screws and decided against full open reduction of the fracture. The proper technique is to make a small incision and then separate the underlying soft tissue using a hemostat to the level of the bone. Spread the jaws of the hemostat and place the guide wire between the jaws, advancing it until it exits the posterior aspect of the bone. This technique prevents injury of the tendons and neurovascular structure during screw placement.
We could only reduce the lateral malleolar fracture satisfactorily through open reduction with standard 1/3rd tubular plate and standard screws. Such plates should not span growth plates as longitudinal bone growth may be impaired. The surgeon should position the foot in a neutral position as joint stiffness is common in pilon fractures and tightness of the ankle joint posterior capsule may result in equinus contraction as a result of positioning in plantarflexion.
Key Post-Op Considerations
Post-op care consisted of a dressing change and no weightbearing. When sufficient healing occurred with verification by serial X-ray, we removed the external fixator, and the patient began partial weightbearing and physical therapy. The boy has progressed very well in his healing course to full, unguarded weightbearing as comfortably tolerated. In this case, we encouraged the patient to avoid vigorous actives until full radiographic healing has occurred. I had the patient begin taking cholecalciferol (vitamin D3) supplementation at 1,200 units per day and will reevaluate this in six months.
Dr. DuRussel is the Chief of Podiatry and the Acting Chief of Surgery at the Northern Navajo Medical Center in Farmington, NM.
References
1. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. The National Academies Press, Washington, DC, 2011.
2. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7):1911-30.
3. Northern Navajo Medical Center, Department of Health and Human Services – Indian Health Services. Pharmacy guidelines pre-surgical prophylaxis for orthopedic procedures. Available at https://www.ihs.gov/navajo/healthcarefacilities/shiprock/ .
4. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Am J Health Syst Pharm. 2013; 70(3):195-283
