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07 Jun 2024
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Bilateral 43C3 Pilon Fractures with Right Grade 3A Open Fracture

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Clinical Details

Clinical and radiological findings:  A 26-year-old male sustained bilateral pilon fractures after a suicide jump. The right side presented as a grade 3A open fracture (AO/OTA 43C3) with a wound on the medial calcaneus from a large metaphyseal fragment protruding distally. The left side was a closed fracture (AO/OTA 43C3). Initial management included bilateral external fixation and irrigation and debridement (I&D) by a non-trauma orthopaedic surgeon.

Preoperative Plan

Planning remarks:  The preoperative plan involved staged procedures. For the right side, repeat I&D, external fixator adjustment, removal of devitalized fragments, application of vancomycin powder, and open reduction and internal fixation (ORIF) of the fibula were planned. For the left side, external fixator adjustment and fibula ORIF were planned. Ten days post-initial fixation, staged left tibial pilon ORIF and removal of the external fixator were planned. Fourteen days post-initial fixation and repeat I&D, staged right tibial pilon ORIF with large iliac crest bone grafting and removal of the external fixator were planned.

Surgical Discussion

Anatomical surgical approach:  An extended anteromedial approach was utilized for both sides. A longitudinal incision was made along the anteromedial aspect of the tibia, extending from the distal third of the tibia to the talar neck. The incision was deepened through the subcutaneous tissue and fascia, taking care to protect the saphenous vein and nerve. The periosteum was elevated subperiosteally to expose the fracture site. For the right side, additional iliac crest bone grafting was performed to address bone loss.

Operative remarks: 

The surgeon noted that the extended anteromedial approach provided excellent exposure for both fractures. The large iliac crest bone graft on the right side incorporated well into the fracture site. Temporary TPN dysfunction was observed following the accident but resolved fully within three months. The soft tissues on the open side also recovered well.

Postoperative protocol:   Postoperatively, the patient was advised to avoid weight-bearing on both lower extremities for six weeks, followed by partial weight-bearing as tolerated. Range of motion exercises for the ankle joint were initiated early to prevent stiffness. Full weight-bearing was allowed at three months postoperatively.

Follow up:   Not specified. Case originally posted on LinkedIn by : Erik Hasenboehler MD FACS - Chief of Orthopaedic Trauma Holy Spirit Hospital Penn State Health Orthopaedic Institute of Pennsylvania

Orthopaedic implants used:   - External Fixator - Vancomycin Powder - Iliac Crest Bone Graft - Stryker Variax Plates and Screws

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  • United States ,
  • Area of Specialty - General Trauma
  • Position - Other Speciality
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