By Raymond DuRussel, DPM, ABLES, ACLES
Case study: 15 old MALE who presented to the Emergency Department with a Salter Harris type 4 pilon fracture of the right tibial and distal oblique fracture of the fibula with mild comminution. DOI: 03/27/16. While running and kicking a soccer ball collided he sustaining an injury to his right leg. The ED obtained radiograms and splinted his extremity. The following day he was seen by Dr. Eric Haag in the Podiatry lower extremity fracture clinic where pre-surgical evaluation and planning was completed. A Jones Compression wrap was applied and Cam-boot. He was then discharged from the clinic on crutches with instructions to ice and elevate; strict no weight bearing. Surgical reduction was completed 4-1-16.
Splintage was removed from the right lower extremity. Clinical and radiographic exam revealed closed significantly displaced Salter Harris type 4 fracture of the distal tibia that may be classified as a pilon fracture. The distal shaft of the right fibula displayed a displaced oblique fracture extending from the diaphysis into the metaphysis with some comminution. The fibular fracture did not extend into the distal fibular ephysis. After the exam was completed, we applied a well-padded Jones Compression wrap and cam-boot while he awaited surgical reduction and stabilization.
Patient was sent to Physical Therapy for no weight bearing gait training. Labs consisted of CBC, Chem-7, and Vitamin D 25(OH). The labs were unremarkable except Vitamin D, 19.5 ng/ml. This is consistent with deficiency consistent with decreased bone strength. Chlorhexidine gluconate 2% cloth bath was ordered to be completed at home for the 2 days prior to the scheduled surgery. Ancef, 2gram IVPB was ordered to be administered before the procedure. In our hospital, Ancef is ordered according to body weight. The guidelines we use are as follows: up to 60kg one gram Ancef; 61 to 199kg two grams; 200 up three grams . SCD was ordered for the contralateral extremity for DVT prophylaxis.
We positioned the patient in the supine position with right thigh tourniquet applied. General anesthesia was employed and muscle paralysis. Under C-arm guidance closed reduction was completed. It should be noted that closed reduction of the distal tibial would not have been successful without muscle paralysis. The Salter Harris type 4 pilon fracture reduction of the distal tibia was obtained with some manipulation difficulty. C-arm evaluation revealed very good reduction. Perfect reduction was not attainable without open reduction, which was discussed and dismissed because the benefit did not justify the risks of further soft tissue envelope trauma beyond this severe fracture.
Four half-pins were placed. One of the half-pins was placed in the medial calcaneus, just anterior to the calcaneal apophysis to avoid injury to the growth plate. The second pin was then placed in the head of the talus, just proximal to the articulation with the navicular. C-arm guidance is needed for proper placement. If there is a question of proper placement of these half-pins, it is recommended that a thin k-wire be placed near the desired pin location, and then evaluated with c-arm for placement and alignment. The k-wire then will act as an excellent alignment guide. Keeping one pin in the calcaneus and the 2nd in the head of the talus provides for an excellent, stable foundation. We do not recommend placing the pin in the neck of the talus, as it is very vascular, and not as stable as the head of the talus.
The remaining two half-pins are placed in the diaphysis of the tibia aligned so that the external fixator may be attached to the medial aspect of the leg. The post fixation x-ray shows good placement for the external fixation half pins. The external fixator was then applied and tightened to maintain reduction. We elected to augment the tibia reduction stability by placing two 4.5mm partially threaded cannulated screws from anterior tibia to posterior. A review of the CT radiograph reveals why the extra percutaneous screws were used and decision against full open reduction of the fracture. Proper technique is to make a small incision, then separate the underlying soft tissue using a hemostat to the level of the bone. Spread the jaws of the hemostat and place the guide wire between the jaws advancing it until it exits the posterior aspect of the bone. This technique insures that tendons and neurovascular structure are not injured in screw placement.
The lateral malleolar fracture could only be reduced satisfactorily by open reduction with standard 1/3rd tubular plate and standard screws. Such plates should not span growth plates as longitudinal bone growth may be impaired. See the pre and post-operative x-rays. It should be mentioned that the foot should be positioned in the neutral position (90 degree to the leg) as joint stiffness is common in pilon fractures, and tightness of the ankle joint posterior capsule may result in equinus contraction as a result of positioning in plantarflexion.
Post Op care consisted as dressing change and no weight bearing. When sufficient healing has been obtained and verified by serial x-ray, the external fixator was removed and partial weight bearing and Physical Therapy began. The boy progress very well in his healing course to full, unguarded weight bearing as comfortably tolerated. No vigorous actives are allowed until full radiographic healing is noted. Cholecalciferol supplementation has been started at 1200 units per day, and will be re-evaluated in 6 months.
 Vitamin D deficiency has been defined by the Institute of Medicine and an Endocrine Society practice guideline as a level of serum 25-OH vitamin D less than 20 ng/mL (1,2). The Endocrine Society went on to further define vitamin D insufficiency as a level between 21 and 29 ng/mL (2). IOM (Institute of Medicine). 2010. Dietary reference intakes for calcium and D. Washington DC: The National Academies Press. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. JCEM. 2011 Jul; 96(7):1911-30.
 Pharmacy guidelines pre-surgical prophylaxis for orthopedic procedures; Northern Navajo Medical Center, Department of Health and Human Services – Indian Health Services
 Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Am J Health-Syst Pharm. 2013:; 70:195-283
 TEMPFIX External Fixation System; BIOMET