Pilon Fractures of the Ankle: Fixation With a Plate and Screws

Pilon Fractures of the Ankle: Fixation With a Plate and Screws

In this surgical demonstration, a pilon fracture of the left ankle will be repaired using plates and screws. Before fixing the patient’s injury, x-rays were taken in the emergency room, showing significantly displaced tibia and fibula fractures.

Other injuries are seen, including a fracture that has come through the skin on the inside of the ankle. The fracture also extends into the ankle joint, typical of a pilon fracture.

Before repairing this fracture with plates and screws, the patient was placed into an external fixator to stabilize the initial injuries. A CT scan shows the patient's injuries after placing the external fixator, demonstrating the stabilized alignment. Given the significant injuries and multiple fragments of bone, including a large piece in the back of the tibia, 3 plates will be placed.

To address the large fragment in the back of the tibia and the fibular fracture, the surgeon will need to make an incision on the back of the left leg. The patient is shown lying on their stomach with the surgical incision being made between the tibia and fibula.

Here, the surgeon identifies the broken fibula and will begin by placing it into the correct position. Once the fibula is placed into alignment, the surgeon can also place the large fragment at the back of the tibia into alignment with 2 wires.

Then, going back to the fibula, a plate can be sized and placed on the bone. The surgeon is shown placing a wire through the plate and bone to hold the position of the plate to the bone.

Next, the surgeon will use a drill and drill guide to make a hole for the first screw. After the hole is drilled through the bone, it will be measured with an instrument called a depth gauge, so the appropriate-sized screw is used. The screw will then be placed with a power driver and finished with a hand driver.

This x-ray shows that the process has been repeated for several additional screws. The 2 wires previously placed in the tibia fragment are shown as well. The surgeon will come back to the fibula later to place the remaining screws in the plate. If the screws are placed now, it will prevent the surgeon from being able to see the tibia repair on x-rays adequately.

The surgeon then directs attention to the fracture at the back of the tibia. A plate is chosen and placed on the back of the tibia through the same incision previously used for the fibula. Two wires are used to hold the plate to the bone.

Then the surgeon will drill a hole for the first screw. Again, the hole will be measured, and the screw is placed. This process will be repeated for all other necessary screws. The surgeon will use a type of screw called a locking screw in some of the holes. The combination of locking and nonlocking screws allows adequate compression of the fracture sites and proper placement of the plate to allow for healing. Once this is repaired, the final screws can be inserted into the fibula plate.

Here, both plates are shown with the fracture lines together for optimal healing. This surgical incision will be sutured closed, and a dressing will be placed.

For the final stage of the surgery, the fractures at the front of the tibia will be addressed. The patient will be turned over and placed on their back so an incision can be made to the front of the leg.

The fracture lines at the front of the ankle are then seen. The surgeon will start by working to restore the ankle joint surface by addressing the multiple fracture fragments seen.

The large fragment at the front of the ankle is pinned in place with 2 wires. Two other wires are used to hold the fracture fragment on the inside of the ankle joint.

Two small screws, called lag screws, are placed directly across a smaller fracture fragment at the base of the tibia to compress these smaller pieces and align the front of the joint. The surgeon has also now placed 2 screws across the fragment to the inside of the ankle.

Once the joint is aligned, a plate will be placed on the front of the tibia. In a similar fashion to the other plates and screws, the surgeon will drill, measure, and then fill the holes as required to maintain the best alignment and compression of the fracture. The temporary wires will all be removed during this process.

Final x-rays will be taken from multiple angles to confirm that the fractures are in alignment and that the plates and screws are in place. The incision in the front of the leg will be sutured closed, and dressings and a splint will be applied. The surgery is now complete.