Imaging for pilon fractures – Indications Part II May 2023

by Nick Strasser, MD


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Often, patients with a pilon fracture end up with a lot of imaging.  Between multiple trips to the OR, applications of external fixators, and CT scans (sometimes with angiograms), it can be a bit overwhelming making sense of imaging.Want to know a secret that will set you apart and gain mad respect from the surgery team???

Most of the time, you can generate a plan by looking at only 4 images!Injury Radiograph Dictates the Plate Position
   Understand the forces you need to resist!

Injury Films – I think these are so important as they tell us a lot about the deforming forces.  As Jan Szatkowski stated, “Just do what a fifth grader would do.”  Is it in varus (foot is medial to the tibia)?  Push it back with a medial plate!  Valgus (foot is lateral to the tibia)?  Push it back with an anterolateral plate!

Oversimplified?  Maybe, but it’s a good framework from within which to start.

What about the CT scan?There are so many fancy cuts and 3D renderings that can be generated.  I think these are all helpful but IMO, the most important cut is the axial cut at the joint line.Think of this as a map…showing you how to best access the articular fragments

(remember principle #2? – reduce the articular surfaces)This axial cut will show you the primary fracture fragments.  

As you look at these images, you can start to understand how you are going to best be able to access the fracture planes and use those to your advantage to look directly at the fragments you are trying to reduce and fix. This is by no means a comprehensive one-size fits all approach to the pilon.  

As is frequently referenced in the military, “The enemy also gets a vote”. In this case, your approach and ideal fixation can be affected by open wounds, blistering, abrasions etc.  But this will get you close.

Looking forward to next month where we will cover Talus Fractures.

June 20th, 7:30 pm central time!

Sign up link here!!!

Just a couple terms I thought I would include to clarify:Varus = foot is push to the midlineValgus = foot is pushed outsideCole,Mehrle etal.

The Pilon Map Fracture Lines and Comminution Zones in OTA/AO Type 43C3Pilon Fractures. Journal of Orthopaedic Trauma: July 2013 – Volume 27 – Issue 7- p e152-e156
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