Towards an orthoplastic dynamic soft tissue classification for closed ankle pilon fractures

When sufficient energy is imparted on bone to cause fracture, that energy also causes soft tissue injury. The “orthoplastic” management of open fractures is well established, however, its role in closed fractures is nascent. An orthoplastic approach to closed ankle pilon fracture (APF) is of particular value. APFs are high-energy intra-articular distal tibial plafond fractures, usually associated with comminution and soft tissue disruption. To achieve anatomical reduction, an open reduction and internal fixation (ORIF) is usually required. However, dissecting the soft tissue for ORIF, in already traumatized tissues, creates additional surgical trauma which can lead to poor outcomes with high rates of wound complications. Watson et al. demonstrated that the degree of initial soft tissue injury in APF is a predictor of poorer patient outcomes regardless of the degree of skeletal injury.[ 1 Watson J.T. Moed B. Karges D. Cramer K. Pilon fractures. Clin Orthop Relat Res. 2000; : 78-90 Crossref PubMed Scopus (151) Google Scholar ] To mitigate this issue, strategies such as delayed or staged ORIF, or definitive treatment with circular or spanning external fixation alone have been popularized to allow soft tissue resuscitation with improved outcomes. As such, key dynamic orthoplastic decisions as to “how” and “when” to treat APF are mediated not only by the state of the bone, but also by the soft tissue envelope.