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Pilon-Frakturen

Teil 1: Diagnostik – Versorgungsstrategie – Zugänge

Pilon fractures

Part 1: Diagnostics, treatment strategies and approaches

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Zusammenfassung

Intraartikuläre Frakturen der distalen Tibia (Pilon-Frakturen, Pilon-tibiale-Frakturen) werden in der Regel durch axiale Stauchungskräfte in Kombination mit Torsionsmomenten verursacht. In der Diagnostik hat sich neben der orientierenden, konventionell radiologischen Projektionsradiographie die dreidimensionale Schnittbildgebung mit CT und zweidimensionalen Rekonstruktionen durchgesetzt. Die Behandlung ist häufig erschwert durch komplexe Frakturformen und dünnvolumige Weichteildeckung. Die Behandlungsstrategie beinhaltet die mehr oder weniger offene Reposition und innere Osteosynthese mit Platten und Schrauben, die externe Fixation mit in der Regel gelenküberbrückenden Konstruktionen oder Kombinationen aus beiden. Die meisten Behandlungsprotokolle bestehen heute im mehrschrittigen Vorgehen mit zunächst externer gelenküberbrückender Fixation, einer Abschwellphase und späterem Wechsel auf eine interne Osteosynthese. Damit konnte die Rate der Weichteilkomplikationen und Infektionen gesenkt werden. Die Zugangsplanung orientiert sich nach dem im 3-D-Datensatz analysierten Frakturmuster und den daraus entwickelten Strategien zur Gelenkrekonstruktion.

Abstract

Intraarticular fractures of the distal tibia (pilon fractures) are caused by axial forces, usually in combination with torsional moments. Routine diagnostics include plain films and three dimensional (3D) imaging with computed tomography (CT). Treatment is often impaired by complex fracture configurations and thin soft tissue layers. The management of complex pilon fractures with soft tissue injuries has seen many trends, with changes toward staged protocols of temporary external fixation followed by delayed open reduction and internal fixation (ORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO) techniques and special implants, the benefits of negative pressure wound sealing and early „fix and flap“ efforts to reconstruct soft tissue defects. Reduction and fixation must involve respectful management and careful handling of soft tissues in order to minimize the well-known complications of this difficult fracture. The proper approach is one of the keys to success. Approach planning is based on the careful and thorough analysis of the fracture pattern in the 3D data set, which is the basis for a successful strategy for articular reconstruction.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Krettek und S. Bachmann geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Correspondence to C. Krettek FRACS, FRCSEd.

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Krettek, C., Bachmann, S. Pilon-Frakturen. Chirurg 86, 87–104 (2015). https://doi.org/10.1007/s00104-014-2895-7

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