Surgical Discussion

Patient positioning:  The patient was initially positioned prone to optimize visualization and implant placement for the posterolateral approach. Subsequently, the patient was repositioned supine for the anteromedial approach.

Anatomical surgical approach:  The posterolateral approach involved a longitudinal incision along the posterior aspect of the fibula, allowing access to the Volkmann fragment and fibula. The anteromedial approach was performed through a longitudinal incision over the medial aspect of the distal tibia, providing access to the articular surface for reduction and fixation.

The surgeon emphasized the importance of approach selection based on soft tissue condition and access to the articular injury. In this B type pilon fracture, fragment-specific buttress plates were utilized for stabilization. The surgeon noted the complexity of distinguishing between varus pilon fractures and severe supination-adduction (SAD) ankle injuries, highlighting recent literature that has refined understanding of these patterns.

Postoperative protocol:   Postoperative rehabilitation included early range of motion exercises with weight-bearing as tolerated, progressing to full weight-bearing as healing allowed.

Follow up:   Not specified.

Orthopaedic implants used:   External fixator, fragment-specific buttress plates, Kirschner wires for temporary fixation.