M.E.Müller: Atlas: Fracture 43-B3

Tibia/Fibula, Distal,
partial articular fracture,
multifragmentary depression 0,25% of the total
1,30% of the tibia
6,69% of the segment

18 fractures
13,1% group
44%M, 56%F

49 fractures
35,8% group
63%M, 37%F

70 fractures
51,1% group
66%M, 34%F

Sagittal +Q Frontal +Q Metaphyseal multifragmentary +Q

These are multifragmentary, partial articular fractures of the tibial pilon, with a depression predominant in the frontal or in the sagittal plane. Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995.
Surgeon. AO Documentation Centre. Davos.

The case illustrated in the upper half of the page has an special interest because the bimalleolar fracture masks the central depression. Reconstruction of the malleoli is essential for the lateral stability of the ankle. The general pattern of the reduction is obtained by first restoring the length of the fibula. The medial malleolus, once it is reduced, frames the multifragmentary depression of the articular surface, which reduction will have to be supported by cancellous bone graft and fixed by whatever means: in these case by simple screws that hold both cortices together.

When the fibula is fractured, it is reduced and fixed with a one-third tubular plate. If a rupture of the syndesmosis is present, it is stabilized with a suprasyndesmotic tibio-fibular screw. If the tubercle of Chaput is avulsed, it is fixed with one or two 3.5 mm cancellous screws with washers. The pilon fracture, that involves mainly its anterior portion, is protected with a plate of a size proportionate to the size of the pilon.

In the illustrated case, two medial screws perform interfragmentary compression in the sagittal plane and, along with the plate screws, reinforce the pilon. The small fragment T plate is a resort for tibias of a small size.

preoperative preoperative

+ 1 year + 1 year

preoperative preoperative

+ 1 year + 1 year

These are partial articular fractures of the tibial pilon, with depression and metaphyseal multifragmentation. Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995.
Surgeon. RO.

A very important point of the preoperative planning is to decide which level should be approached first. In some cases it is preferable to first reduce and fix the diaphyseal fracture because the articular fragments will then automatically gather together. In other cases it may be preferable to do it the other way around.

In the illustrated case the fibula is intact, an advantage present in the 20% of the cases. The tibia has a large anterior fragment in the frontal plane and an impacted

intermediate fragment that must be anatomically reduced and fixed with isolated screws from inside out. The large anterior fragment that ascends to the metaphysis is fixed with a one-third tubular plate, flattened and contoured at its distal end, compressed against the bone by a cancellous lag screw. This plate must be contoured in such a way that, once the proximal screws are placed, provides interfragmentary compression and buttress effects.

preoperative preoperative

postoperative postoperative

+ 6 months + 6 months




						Tibia/Fibula, Distal, partial articular fracture, multifragmentary depression	0,25% of the total 1,30% of the tibia 6,69% of the segment






These are multifragmentary, partial articular fractures of the tibial pilon, with a depression predominant in the frontal or in the sagittal plane.		Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995. Surgeon. AO Documentation Centre. Davos.

The case illustrated in the upper half of the page has an special interest because the bimalleolar fracture masks the central depression. Reconstruction of the malleoli is essential for the lateral stability of the ankle. The general pattern of the reduction is obtained by first restoring the length of the fibula. The medial malleolus, once it is reduced, frames the multifragmentary depression of the articular surface, which reduction will have to be supported by cancellous bone graft and fixed by whatever means: in these case by simple screws that hold both cortices together.	When the fibula is fractured, it is reduced and fixed with a one-third tubular plate. If a rupture of the syndesmosis is present, it is stabilized with a suprasyndesmotic tibio-fibular screw. If the tubercle of Chaput is avulsed, it is fixed with one or two 3.5 mm cancellous screws with washers. The pilon fracture, that involves mainly its anterior portion, is protected with a plate of a size proportionate to the size of the pilon. In the illustrated case, two medial screws perform interfragmentary compression in the sagittal plane and, along with the plate screws, reinforce the pilon. The small fragment T plate is a resort for tibias of a small size.






These are partial articular fractures of the tibial pilon, with depression and metaphyseal multifragmentation.		Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995. Surgeon. RO.

A very important point of the preoperative planning is to decide which level should be approached first. In some cases it is preferable to first reduce and fix the diaphyseal fracture because the articular fragments will then automatically gather together. In other cases it may be preferable to do it the other way around. In the illustrated case the fibula is intact, an advantage present in the 20% of the cases. The tibia has a large anterior fragment in the frontal plane and an impacted	intermediate fragment that must be anatomically reduced and fixed with isolated screws from inside out. The large anterior fragment that ascends to the metaphysis is fixed with a one-third tubular plate, flattened and contoured at its distal end, compressed against the bone by a cancellous lag screw. This plate must be contoured in such a way that, once the proximal screws are placed, provides interfragmentary compression and buttress effects.