Tibial pylon fractures

We consider a fracture of the tibial pylon to be any fracture of the distal metaphysis of the tibia that reaches the ankle joint.

These fractures are different from bimaleolar fractures in that the tibioperoneal ligament remains intact in almost all cases. In those cases in which the fibula remains undamaged, there is at least one tibial fragment joined to it by the tibioperoneal syndesmosis. This explains why traction methods can reduce these fractures. Nor is the deltoid ligament torn.

• Axial compression (high energy): falling from a height or traffic accidents. The force is directed axially through the talus towards the pylon of the tibia and causes impaction or subsidence of the articular surface; it can be associated with a large comminution.

• Rotational force (low energy): sports accident. The main mechanism is a torsion combined with a force in varus or valgus. It produces two or more large fragments with minimal comminution of the articular surface.

• Combined compression and shear injury. This type of fracture has both compression and shear components. The vector of these two forces determines the fracture pattern.

As these are high-energy injuries, they are often associated with other specific fractures: calcaneal, tibial plate, pelvis and vertebral.

Reduction of joint fragments can be performed percutaneously or through small limited incisions with the aid of various types of forceps and radioscopic control to assess fracture reduction.

It is possible to stabilise the metaphyseal fracture with plates or with an external fixator, which may or may not extend beyond the ankle joint. Grafting of metaphyseal defects with some type of osteoconductive material is indicated.

Internal fixation:

The best way to achieve a precise reduction of the articular surface is by open reduction of the fracture and fixation with a plate. To minimize complications from the use of plaques, the following techniques have been recommended:

• In high-energy fractures, delay surgery, while using an external fixator beyond the joint, until definitive surgical treatment can be performed.
• Use small, precontoured, low profile implants and mini-fragment screws.
• Use indirect reduction techniques to minimize soft tissue denudation.