M.E.Müller: Atlas: Fracture 43-C3

Tibia/Fibula, Distal,
complete articular fracture,
multifragmentary 0,40% of the total
2,05% of the tibia
10,60% of the segment

58 fractures
26,7% group
76%M, 24%F

48 fractures
22,1% group
70%M, 30%F

111 fractures
51,2% group
70%M, 30%F

Epiphyseal +Q Epiphysio-metaphyseal +Q Epiphysio-metaphysio-diaphyseal +Q

These are complete articular fractures, multifragmentary, limited to the epiphyseal area. Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995.
Surgeon. RO.

The reduction and stable internal fixation of the fibula is the first surgical step, essential in order to recontruct the length and stabilize the lateral column of the ankle mortice. The medial malleolus is always fractured and should be reduced and fixed like in the bimalleolar fractures. The intermediate fragments of the pilon, between the two malleoli, constitute a complete multifragmentary articular fracture that will have to be reconstructed according to the skills of the surgeon and to the characteristics of the fracture. The addition of

cancellous bone graft is essential, as well as it is the use of Kirschner wires, which, when adequately placed, can be substituted by cannulated screws.

The future of the articular function will depend on the condition of the articular cartilage. In any case, a good reduction molded to the talar dome should always be attempted because a good reconstruction of the pilon will make the possible arthrodesis easier at a later date.

preoperative preoperative

postoperative postoperative

+ 6 months + 6 months

+ 4 years + 4 years

These are complete articular fractures, multifragmentary, involving the epiphysis and the metaphysis. In the C3.3 subgroup, the multifragmentation extends into the diaphysis. Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995.
Surgeon. JG, RO.

Like in the previous subgroup, the reduction and stabilization should be attempted, although it is much more difficult to perform in these subgroups, especially when the fractures are open and associated to a dislocation. A primary arthrodesis might be indicated. An arthrodesis at a later stage is quite possible.

However, cases like the one shown in the bottom half of the page may be salvaged with an acceptable function. The metaphyseal-diaphyseal bone loss was substituted by a generous amount of cortico-cancellous iliac bone

graft and the multiple fragments of the fracture site, probably devitalized, were left in place without manipulating them and without attempting an impossible anatomic reduction.

The double plating internal fixation technique allowed early range of motion of the ankle, although it was kept non-weight-bearing for three months. The postoperative radiographical control demonstrates the described characteristics of the surgical procedure. The fracture healed with a voluminous callus.

preoperative preoperative + 1 year

preoperative preoperative

+ 6 months + 6 months

These are complete articular fractures, multifragmentary, involving the epiphysis, the metaphysis, and definitely extending into the diaphysis. Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995.
Surgeon. RO.

These fractures are the most difficult ones to treat among the fractures of this segment and, indeed, they are the most difficult ones of the whole skeleton. Their study by CT scan is essential and a meticulous preoperative planning is mandatory.

When the fibula is fractured, its reduction and internal fixation is essential. When the fibula is not fractured (like in the illustrated case), the difficulty is much less because the length is maintained and at least one of the fragments of the pilon remains in its place, fastened by the syndesmosis.

The fracture of the tibia must be reduced from proximal to distal and internally fixed with isolated lag screws. Once the epiphyseal fracture is reduced and provisionally fixed, placement of an extra-long cloverleaf plate, with buttress and neutralization functions, will stabilize the assembly. It is wise and almost always necessary to add another plate on the anterior aspect (double plate), without forgetting the essential cancellous bone grafting.

preoperative preoperative preoperative

postoperative + 4 months + 4 months

preoperative preoperative + 1 month

+ 1 year + 3 years + 3 years

preoperative preoperative preoperative preoperative

+ 0 month + 0 month + 3 month + 3 month




						Tibia/Fibula, Distal, complete articular fracture, multifragmentary	0,40% of the total 2,05% of the tibia 10,60% of the segment






These are complete articular fractures, multifragmentary, limited to the epiphyseal area.		Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995. Surgeon. RO.

The reduction and stable internal fixation of the fibula is the first surgical step, essential in order to recontruct the length and stabilize the lateral column of the ankle mortice. The medial malleolus is always fractured and should be reduced and fixed like in the bimalleolar fractures. The intermediate fragments of the pilon, between the two malleoli, constitute a complete multifragmentary articular fracture that will have to be reconstructed according to the skills of the surgeon and to the characteristics of the fracture. The addition of	cancellous bone graft is essential, as well as it is the use of Kirschner wires, which, when adequately placed, can be substituted by cannulated screws. The future of the articular function will depend on the condition of the articular cartilage. In any case, a good reduction molded to the talar dome should always be attempted because a good reconstruction of the pilon will make the possible arthrodesis easier at a later date.






These are complete articular fractures, multifragmentary, involving the epiphysis and the metaphysis. In the C3.3 subgroup, the multifragmentation extends into the diaphysis.		Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995. Surgeon. JG, RO.

Like in the previous subgroup, the reduction and stabilization should be attempted, although it is much more difficult to perform in these subgroups, especially when the fractures are open and associated to a dislocation. A primary arthrodesis might be indicated. An arthrodesis at a later stage is quite possible. However, cases like the one shown in the bottom half of the page may be salvaged with an acceptable function. The metaphyseal-diaphyseal bone loss was substituted by a generous amount of cortico-cancellous iliac bone	graft and the multiple fragments of the fracture site, probably devitalized, were left in place without manipulating them and without attempting an impossible anatomic reduction. The double plating internal fixation technique allowed early range of motion of the ankle, although it was kept non-weight-bearing for three months. The postoperative radiographical control demonstrates the described characteristics of the surgical procedure. The fracture healed with a voluminous callus.






These are complete articular fractures, multifragmentary, involving the epiphysis, the metaphysis, and definitely extending into the diaphysis.		Ref. U. Heim. The pilon tibial fracture. WB Saunders. 1995. Surgeon. RO.

These fractures are the most difficult ones to treat among the fractures of this segment and, indeed, they are the most difficult ones of the whole skeleton. Their study by CT scan is essential and a meticulous preoperative planning is mandatory. When the fibula is fractured, its reduction and internal fixation is essential. When the fibula is not fractured (like in the illustrated case), the difficulty is much less because the length is maintained and at least one of the fragments of the pilon remains in its place, fastened by the syndesmosis.	The fracture of the tibia must be reduced from proximal to distal and internally fixed with isolated lag screws. Once the epiphyseal fracture is reduced and provisionally fixed, placement of an extra-long cloverleaf plate, with buttress and neutralization functions, will stabilize the assembly. It is wise and almost always necessary to add another plate on the anterior aspect (double plate), without forgetting the essential cancellous bone grafting.