Zusammenfassung
Frakturen des Pilon tibiale stellen aufgrund der häufig komplexen Frakturmorphologie und der Vulnerabilität der Weichteile eine große therapeutische Herausforderung dar. Komplikationen treten unter der Therapie häufiger auf als bei Malleolarfrakturen. Um Komplikationen wirksam vorbeugen zu können, muss der Behandler um die speziellen Risiken dieser Verletzungen wissen. Bei den frühen Komplikationen stehen Weichteilnekrosen, verbliebene Fehlstellungen, der frühe Repositionsverlust und die Infektion im Vordergrund. Die Weichteile müssen zudem engmaschig auf frühe Zeichen eines Kompartmentsyndroms oder eines chronischen regionalen Schmerzsyndroms (CRPS) überwacht werden. Späte Komplikationen wie Knochennekrosen mit und ohne Achsfehlstellungen, Pseudarthrosen und Arthrosen des oberen Sprunggelenks (OSG) lassen mehr Zeit für die Analyse und Therapie. Die Therapie der Pilon-tibiale-Fraktur muss bis zur sicheren Knochenheilung engmaschig überwacht werden, um Komplikationen frühzeitig erkennen und behandeln zu können. Nur so kann das bestmögliche Behandlungsergebnis erzielt werden.
Abstract
Because of the complex fracture morphology and vulnerable soft tissue coverage, fractures of the tibial pilon are difficult to treat. Complications are more common than in bi- or trimalleolar fractures. The surgeon has to know about the special risks of these injuries to avoid complications. Early complications are soft tissue necrosis, persisting fragment dislocations after surgery, loss of reposition and deep wound infection. The surgeon has to be aware of early signs of compartment-syndrome and chronic regional pain syndrome (CRPS). In late complications such as bony necrosis with or without deviation, non-union and osteoarthrosis of the ankle joint give the surgeon more time for planning the therapy. Intensive monitoring until bone healing is necessary in tibial pilon fractures to detect complications early and start the therapy immediately. This kind of therapy results in the best outcome for these patients.
This is a preview of subscription content, log in via an institution to check access.
Literatur
Abd-Almageed E, Marwan Y, Esmaeel A, Mallur A, El-alfy B (2015) Hybrid external fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C tibial plafond fractures. J Foot Ankle Surg 54(6):1031–1036
Ballal A, Rai HR, Shetty SM, Mathias LJ, Shetty V, Shety A (2016) A prospective study on functional outcome of internal fixation of tibial pilon fractures with locking plate using minimally invasive plate osteosynthesis technique. J Clin Diagn Res 10(1):RC01–4
Chan R, Taylor BC, Gentile J (2015) Optimal management of high-energy pilon fractures. Orthopedics 38(8):e708–e714
De-las-Heras-Romero J, Lledo-Alvarez AM, Lizaur-Utrille A, Lopez-Prats FA (2017) Quality of life and prognostic factors after intra-articular tibial pilon fractures. Injury. doi:10.1016/j.injury.2017.03.023
Dickson KF, Montgomery S, Field J (2001) High energy plafond fractures treated by a spanning external fixateur initially and followed by a second stage open reduction internal fixation of the articular surface – preliminary report. Injury 32(Suppl 4):D92–D98
Duckworth AD, Jefferies JG, Clement ND, White TO (2016) Type C tibial pilon fractures: short- and long-term outcome following operative intervention. Bone Joint J 98-B(8):1106–1111
Guenther D, Kokenge T, Jacobs O, Omar M, Krettek C, Gehrke T, Kendoff D, Haasper C (2014) Excluding infections in arthroplasty using leucocyte esterase test. Int Orthop 38(11):2385–2390
Hardeski D, Gaski G, Joshi M, Venezia R, Nascone JW, Sciadini MF, O’Toole RV (2016) Can applied external fixators be sterilized for surgery? A prospective cohort study of orthopaedic trauma patients. Injury 47(12):2679–2682
Imren Y, Desteli EE, Erdil M, Ceylan HH, Tuncay I, Sen C (2017) Mid-term results of minimally invasive plate osteosynthesis and circular external fixation in the treatment of complex distal tibial fractures. J Am Podiatr Med Assoc 107:3–10
Kent M, Mumith A, McEwan J, Hancock N (2015) The service impact of failed locking plate fixation of distal tibial fractures: a service and financial evaluation at a major trauma centre. Eur J Orthop Surg Traumatol 25(8):1333–1342
Krettek C, Bachmann S (2015) Pilonfrakturen. Chirurg 86(2):187–201
Lomax A, Singh A, Madeley NJ, Senthil Kumar C (2015) Complications and early results after operative fixation of 68 pilon fractures of the distal tibia. Scott Med J 60(2):79–84
Masrouha KZ, Tamim H, Taha A, Sheik Taha AM, Abi-Melhem R, Al-Taki M (2016) Comparison of early adverse events after operative treatment of bimalleolar and trimalleolar fractures versus pilon fractures. J Foot Ankle Surg. doi:10.1053/j.jfas.2016.09.011
Molina CS, Stinner DJ, Fras AR, Evans JM (2015) Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43). J Orthop 12(Suppl1):S7–S13
Rammelt S, Marti RK, Zwipp H (2013) Gelenkerhaltende Osteotomien fehlverheilter Sprunggelenk- und Pilonfrakturen. Unfallchirurg 116:789–796
Rammelt S, Zwipp H (2016) Intra-articular osteotomy for correction of malunions and nonunions of the tibial pilon. Foot Ankle Clin 21(1):63–76
Rüedi TP, Allgöwer M (1979) The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 138:105–110
Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr (2004) A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 18(8 Suppl):32–S38
TRUST Investigators writing group, Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P 3rd, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyat GH (2016) Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ 355:i5351
Viberg B, Kleven S, Hamborg-Petersen E, Skov O (2016) Complications and functional outcome after fixation of distal tibia fractures with locking plate – a multicentre study. Injury 47(7):1514–1518
Vidovic D, Matejcic A, Ivica M, Jurisic D, Elbjer E, Bakota B (2015) Minimally-invasive plate osteosynthesis in distal tibial fractures: results and complications. Injury 46(Suppl 6):96–99
Yadav A, Sikdar J, Anand V, Singh R, Sidhu V (2015) Quantitative measurement of intra-compartmental pressure of the leg in acute traumatic injury: as a routine trend. J Clin Orthop Trauma 6(4):230–235
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
R. Gaulke und C. Krettek geben an, dass kein Interessenkonflikt besteht.
Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.
Additional information
Redaktion
R. Gaulke, Hannover
T. Mittlmeier, Rostock
Rights and permissions
About this article
Cite this article
Gaulke, R., Krettek, C. Pilon-tibiale-Frakturen. Unfallchirurg 120, 658–666 (2017). https://doi.org/10.1007/s00113-017-0366-6
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00113-017-0366-6
Schlüsselwörter
- Pilon-tibiale-Fraktur
- Kompartmentsyndrom
- Chronisches regionales Schmerzsyndrom
- Arthrose oberes Sprunggelenk
- Wundinfektion