Pilon fractures affect the bottom of the shinbone (tibia) at the ankle joint. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice. Wolters Kluwer Health These classifications are less reproducible and do not provide necessary information for proper surgical planning. 43B: partial articular fractures with some connection between part of the joint surface and the diaphysis - again, some series appear to include th… your express consent. Zhang J, Wang H, Pen C, Qu WC, Duan L, Ren J, Li L, Liu Z, Sun T. Medicine (Baltimore). There was no notable difference between the foot and ankle surgeons and orthopaedic surgery residents in the interobserver and intraobserver agreement. Curr Rev Musculoskelet Med. Despite the best treatment, patients sustaining high-energy pilon fractures generally do not return to their previous state of general health or function. Type IV is a fracture through all three elements of the bone, the growth plate, metaphysis and epiphysis. Average AOFAS score was 91,7±7,8 in the Type I of new classification proposed, 87,7±7,8 in the Type II, 82±18,6 in type III, and 67,2±20,9 in type IV. Rev Chir Orthop Reparatrice Appar Mot. “Talar Fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification.” Pilon is french word for pestle,an instrument used for crushing or pounding, 3. 2019 Aug;43(8):1939-1950. doi: 10.1007/s00264-019-04344-8. KEY FACTS • The tibial pilon fracture is a rare, yet devastating injury. 800-638-3030 (within USA), 301-223-2300 (international) According to Ruedi and Allgower classification system: type I: articular fracture with minimal or no displacement doi: 10.1097/MD.0000000000014133. From the Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile (Dr. Palma, Dr. Villa, Dr. Mery, Dr. Abarca, Dr. Mora, Dr. Peña, Dr. Urrutia) and the Foot and Ankle Division, Department of Orthopedic Surgery, Clinica Las Condes, (Dr. Filippi), Santiago, Chile. Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. (2015). Pilon fracture is a type of distal tibial fracture involving the tibial plafond. Posterior pilon fracture is a common type of intraarticular fracture encountered in clinical practice. Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands. A New Classification System for Pilon Fractures Based on CT Scan: An Independent Interobserver and Intraobserver Agreement Evaluation. A new pilon fracture classification system based on CT scan data was recently published, showing almost perfect interobserver and intraobserver agreement among the authors who developed it. Log in to view full text. Aim of the study is to (1) propose a new classification system based on CT scan; (2) to check the prognostic value of this classification and (3) to evaluate its reliability and (4) … High-energy tibial pilon fractures: an instructional review. Ramappa M, Bajwa A, Singh A, Mackenney P, Hui A, Port A. Rüedi-Allgöwer classification and AO/OTA classification for Pilon fractures are widely used until now. access full text with Ovid®. Characteristics and proposed classification system of posterior pilon fractures. PILON FRACTURES Dr Prakashappa T. H. Professor , S.I.T. to maintaining your privacy and will not share your personal information without This website uses cookies. “The operative treatment of intra-articular fractures of the lower end of the tibia.” Clin Orthop Relat Res (138): 105-110. 30 mins. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. Sep 29, 2020 fractures of the tibial pilon Posted By Roald DahlMedia TEXT ID c298c032 Online PDF Ebook Epub Library Total Fractures Of The Tibial Pilon Sciencedirect complete fractures of the tibial pilon are rare and their treatment difficult the pathophysiology includes three groups a high energy trauma motor vehicle injuries with severe articular and soft tissue lesions b [Pilon fractures : Review of diagnostics and classification]. HHS Unfallchirurg. Department of Radiology, Central Military Hospital, U Vojenske´ ... discrimination between posterior malleolar and pilon fractures remains difficult [30]. Methods One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. Pilon fractures may be considered high-energy ankle fractures. You may be trying to access this site from a secured browser on the server. J Orthop Surg Res. There are also associated fractures of the talar dome and tip of the lateral malleolus. Several classification systems exist. The new classification system demonstrated substantial interobserver and intraobserver agreement between evaluators with different levels of expertise in the management of pilon fractures. Correspondence to Dr. Palma: [email protected]. First described by Destot 35 in 1911, ankle fractures that involve the weight-bearing articular surface, or floor, of the distal tibia are known as pilon fractures. 2018 Dec;11(4):537-545. doi: 10.1007/s12178-018-9519-7.  |  O BENGALURE 2. References: Melenevsky, Y., et al. Classification. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. Historical perspective The term”tibial pilon”was first used by DESTOT in 1911,likening the pilon to the pestle. References: Melenevsky, Y., et al. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. There is a comminuted distal tibial fracture extending into the tibial plafond, representing a Pilon fracture. Classification. All registration fields are required. Lippincott Journals Subscribers, use your username or email along with your password to log in. Copyright © 2017 Elsevier Ltd. All rights reserved. 2010 Jun-Sep;20(2-3):61-3. doi: 10.1016/j.foot.2010.06.002. Pilon fractures 1. Sixty-four of 71 fractures healed. These classifications are less reproducible and do not provide necessary information for proper surgical planning. The Weber ankle fracture classification (or Danis-Weber classification) is a simple system for classification of lateral malleolar fractures, relating to the level of the fracture in relation to the ankle joint, specifically the distal tibiofibular syndesmosis.It has a role in determining treatment. Rev Chir Orthop Reparatrice Appar Mot. Clipboard, Search History, and several other advanced features are temporarily unavailable. Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint. Actually, pilon fractures are classified according to AO and Ruedi Allgower classification systems based on X-rays. Morphological characteristics of different types of distal radius die-punch fractures based on three-column theory. Posterior pilon fracture is a common type of intraarticular fracture encountered in clinical practice. 1998. The first sub-grouping is on the degree of cntinuity between diaphysis and metaphysis: 1. Topliss classification These can be challenging to manage, especially when associated with significant soft-tissue injury.  |  2017 Oct;48(10):2311-2317. Palma, Joaquin MD; Villa, Andres MD; Mery, Pablo MD; Abarca, Mario MD; Mora, Andres MD; Peña, Andres MD; Urrutia, Julio MD; Filippi, Jorge MD, MBA. The aim of this study is to: (1) propose a new classification system for the pilon fractures based on the CT scan, useful for the pre-operative surgical planning; (2) check the prognostic value of this classification, and (3) evaluate its reliability and (4) reproducibility. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. The systems used to classify the displaced distal pilon fractures are supposed to ensure the three-dimensional assessment of the fracture and provide high inter- and intra-observer agreement. Pilon fractures affect the bottom of the shinbone (tibia) at the ankle joint. 1998 Apr;84(2):180-8. Pilon fractures are rare, comprising 3 to 10 percent of all fractures of the tibia and 1 percent of all lower extremity fractures, but they involve a large part of the weight-bearing surface of … 2018 Apr;49(4):881-882. doi: 10.1016/j.injury.2018.02.019. USA.gov. Journal of the American Academy of Orthopaedic Surgeons: JAAOS - Journal of the American Academy of Orthopaedic Surgeons28(5):208-213, March 1, 2020. The classification of extraarticular fractures has been less controversial, perhaps because they have been the subject of fewer studies than have intraarticular fractures. Epub 2019 May 15. We retrospectively reviewed 71 cases of pilon fracture. may email you for journal alerts and information, but is committed Notice that the epiphyseal fracture is in the sagittal plane, the fracture through the growth plate is in the axial plane and the metaphyseal fracture is in the coronal plane. What Is the Most Reliable Classification System to Assess Tibial Pilon Fractures? Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. Cleavage fracture with no major articular disruption. Aim of the study is to (1) propose a new classification system based on CT scan; (2) to check the prognostic value of this classification and (3) to evaluate its reliability and (4) reproducibility. When including the II and III subtypes, the overall agreement was still substantial, with a κ value of 0.61 (95% confidence interval: 0.58 to 0.64). Cohen's K value was calculated in order to evaluate the interobserver and intraobserver agreement. Pilon fractures in the distal tibia result from axial forces that can range from low to high energy and produce a spectrum of articular and metaphyseal injuries. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. Fractures that involve the posteromedial plafond extending to the medial malleolus have been described previously in small case series. Injury. Some error has occurred while processing your request. Clinical and radiographic evaluation were performed at a mean follow-up of 36 months. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Palma, Dr. Villa, Dr. Mery, Dr. Abarca, Dr. Mora, Dr. Peña, Dr. Urrutia, and Dr. Filippi. Please try after some time. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification of pilon fractures. Moreover it provides a new treatment-oriented classification for this challenging fracture which affect the quality of life of the patients more than chronic diseases like diabetes and coronaropathy or pelvic fractures. 2019 Jan;98(3):e14133. Foot (Edinb). Pilon fractures may be considered high-energy ankle fractures. According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. Multifragmentary pilon fractures were associated with posterior tibial and flexor digitorum longus tendon entrapment (p < 0.0001 and p = 0.0003 for Ruedi/Allgower and AO-OTA, respectively), and multifragmentary Sanders type 3 or 4 calcaneal fractures were associated with superior peroneal retinacular injury (p = 0.0473) compared to simple fracture patterns. Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents. Interobserver and intraobserver variations in tibial pilon fracture classification systems. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. However, an independent assessment has not been done. Explanation. Theorie et pratique de l’ osteosynthese. According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. Pilon fracture Mechanism. According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. Please try again soon. Notes. This site needs JavaScript to work properly. [Fractures of the tibial pilon. References: Danis R, ed. The AO long bone group universal classification of fractures groups distal tibia fractures as 43. Type I: Intra-articular fracture of the distal tibia without significant displacement Type II: Intra-articular fracture of the distal tibia with significant displacement but minimal comminution Type III: Fracture of distal tibia with severe comminution and significant intra-articular displacement. by the American Academy of Orthopaedic Surgeons. By continuing to use this website you are giving consent to cookies being used. The intraobserver agreement was substantial when considering the main fracture categories (I, II, III, or IV), with a κ value of 0.78 (confidence interval: 0.72 to 0.84), and full agreement at the type level was observed in 76% (324/426) of evaluations. Using the AO classification system the average K weighted value among the five reviewers was 0,51; using Ruedi Allgower classification it was 0,50 and using the new classification system it was 0,88 (p<0.0005). Therefore, the aim of this study was to Please enable it to take advantage of the complete set of features! Bonin, 11 in 1950, described the same fracture as a “plafond” fracture because the fracture disrupted the roof of the ankle joint. Publicationdate 2012-08-23. “Talar Fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification.” Registered users can save articles, searches, and manage email alerts. METHODS: One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. COVID-19 is an emerging, rapidly evolving situation. Type I: Intra-articular fracture of the distal tibia without significant displacement Type II: Intra-articular fracture of the distal tibia with significant displacement but minimal comminution Type III: Fracture of distal tibia with severe comminution and significant intra-articular displacement. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Sep 27, 2020 fractures of the tibial pilon Posted By Eleanor HibbertLibrary TEXT ID c298c032 Online PDF Ebook Epub Library Pilone Tibiale O In Der Kaufberatung fractures of the tibial pilon english edition 6038eur 2 die pilon tibial fraktur klassifikation operationstechnik ergebnisse german edition 7999eur 3 fijacion externa en fracturas del pilon tibial experiencia METHODS: One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. To find in-depth information on ankle fractures, please read Ankle Fractures (Broken Ankle).. A pilon fracture is a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint. J Foot Ankle Surg. Please enable scripts and reload this page. When the fibula was intact, 58% of fractures were partial articular type B. First described by Destot 35 in 1911, ankle fractures that involve the weight-bearing articular surface, or floor, of the distal tibia are known as pilon fractures. The interobserver agreement was substantial regarding the main fracture type (I, II, III, or IV), with an overall κ value of 0.69 (0.65 to 0.72). Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in Type 2. The distal tibial fracture would be designated at “4.3” (e.g., 43-C2) injury, followed by the type and group classification above. Type 3. Paris, France: Masson & Cie, 1949. Typically high energy injuries and occur as a result of an axial loading which drives the talus into the tibial plafond. In addition to the classification of Rüedi and Allgöwer, the classification of pilon fractures has been carried out using the AO classification. A pilon fracture is a type of break that occurs at the bottom of the tibia (shinbone) and involves the weight-bearing surface of the ankle joint. Keywords: Although both extra-articular and intra-articular patterns occur with varying severity, the common concern in all of these injuries is the associated soft tissue injury. If you're not a subscriber, you can: You can read the full text of this article if you: Institutional members METHODS: Ninety-one cases of Pilon fractures classified by four column method and treated by open reduction internal fixation (ORIF) were reviewed from March 2005 to June 2009. A pilon fracture is a fracture of the distal tibia involving the tibial plafond. 2020 Jan-Feb;59(1):48-52. doi: 10.1053/j.jfas.2019.07.002. For more information, please refer to our Privacy Policy. A pilon fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint. Epub 2018 Feb 19. Pilon fractures in the distal tibia result from axial forces that can range from low to high energy and produce a spectrum of articular and metaphyseal injuries. The kappa coefficient (κ) was used to determine agreement among evaluators. This study demonstrated that the new classification system is prognostic, reliable and reproducible. Seventy-one cases of acute pilon fracture were retrospectively collected. Explanation. The purpose of this study was to report our outcomes following fixation of this posterior pilon fracture and to describe a novel classification system to help guide operative planning and fixation. These fractures are also named triplane fractures. Epub 2010 Jul 6. NIH Type 1. All fractures were classified according to AO, Ruedi Allgower and new proposed classification system by 5 surgeons. When the fibula was fractured, nearly 70% were type C complete articular fractures and over half were type C3, the most comminuted. CT scan classification; Interobserver agreement; Pilon fractures; Reliability; Treatment-oriented classification. For immediate assistance, contact Customer Service: Letter to the Editor concerning "Pilon fractures: A new classification system based on CT-scan" by Danilo Leonetti, *, Domenico Tigani (2017). The Rüedi and Allgöwer classification of pilon fractures. Reference: Ruedi, T. P. and M. Allgower (1979). According to the four-column classification scheme, lateral column of 85 cases, posterior column of 66 cases, medial column of 77 cases, and anterior column of 61 cases are involved. Generally, extraarticular calcaneal fractures fall into one of three categories depending on whether the involvement of the calcaneus is anterior, middle, or posterior ( Fig 16 ) ( 5 , 22 ). Ruedi and Allgower Classification of Pilon Fractures. Evolution in Management of Tibial Pilon Fractures. Get new journal Tables of Contents sent right to your email inbox, March 1, 2020 - Volume 28 - Issue 5 - p 208-213, A New Classification System for Pilon Fractures Based on CT Scan: An Independent Interobserver and Intraobserver Agreement Evaluation, Articles in Google Scholar by Joaquin Palma, MD, Other articles in this journal by Joaquin Palma, MD. The treatment of this fracture pattern has been increasingly reported. Description. 8 Three types are included in Rüedi-Allgöwer classification, depending on the displacement of articular surface, metaphyseal and injury extent of fractures, which is easy to remember and to evaluate the outcome of pilon fractures. 2017 Aug;120(8):632-639. doi: 10.1007/s00113-017-0363-9. 2020 Mar 1;28(5):208-213. doi: 10.5435/JAAOS-D-19-00390. NLM Methods One hundred and ten cases (107 patients) of Pilon fractures classified by the four-column theory and treated by ORIF, were reviewed. The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. 43A: extra-articular – most would not recognise these as pilon fractures, although in some series non-articular fractures are included and it can be difficult to tell how many were articular 2. A 'pilon' fracture is any fracture of the distal tibia which involves the articular surface of the tibia - also known as the 'tibial plafond' Ankle - 'Pilon' fracture - Lateral Hover on/off image to show/hide findings Ankle - 'Pilon' fracture - Lateral Classification. Int Orthop. Registered users can save articles, searches, and manage email alerts. Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. The cause of these injuries is frequently violent, and… ... Radiographic features. A good fracture classification system should provide a suitable description of the fractures to facilitate communication between surgeons, show adequate interobserver agreement, guide surgical decision-making, and offer a prognosis for pertinent outcomes in different groups of patients [8, 9, 19].Several classification systems have been suggested for tibial pilon fractures; however, the … Your message has been successfully sent to your colleague. Fracture dislocation with major articular surface disruption, without comminution. He is now 3 weeks from injury and … Bonin, 11 in 1950, described the same fracture as a “plafond” fracture because the fracture disrupted the roof of the ankle joint. Luk (2013) compared pilon fracture types in patients with and without an intact fibula. 800-638-3030 (within USA), 301-223-2300 (international). – Determined by fracture pattern and “primary” injury Pilon Fractures • Post‐op Care – Make it protocol – Strict elevation post‐op: 23 hrs/day (2015). With this type of injury, the other bone in the lower leg, the fibula, is frequently broken as well. Classification. Injury. Obviously there is some potential overlap with the more severe malleolar fractures; pilon fractures are usually understood to be those with involvement of the central plafond, although this has not been formally defined. [email protected]. The treatment of this fracture pattern has been increasingly reported. Data is temporarily unavailable.  |  This article addresses pilon fractures—a specific type of fracture that occurs in the lower leg near the ankle. (OBQ05.93) A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis]. History and etymology. OBJECTIVE: To examine the association between tibial pilon and calcaneal fracture classification and tendon entrapment or dislocation. These can be challenging to manage, especially when associated with significant soft-tissue injury. Failure to identify this fracture pattern has led to poor clinical outcomes and persistent talar subluxation. 2019 Nov 27;14(1):390. doi: 10.1186/s13018-019-1453-x. Pilon Fractures • Approaches & Technique – Beyond this scope – Anteromedial, anterolateral, posterior, anterior, perc, MIPO, percwith IMN, ringed fixation, etc. Palma J, Villa A, Mery P, Abarca M, Mora A, Peña A, Urrutia J, Filippi J. J Am Acad Orthop Surg. 10.1055/b-0036-129629 Distal Tibia Fractures Sean E. Nork Fractures of the distal tibia are among the most difficult injuries facing the orthopaedic traumatologist. To do an independent agreement evaluation of the new pilon fracture classification system with physicians with different levels of expertise in the management of pilon fractures. However, classification of Rüedi-Allgöwer bases only on the X-ray radiogragh, lack of other radiological … Less controversial, perhaps because they have been the subject of fewer studies than have intraarticular....:881-882. doi: 10.1007/s00264-019-04344-8 utility in clinical practice of fewer studies than have intraarticular.. Clinical and radiographic evaluation were performed at a mean follow-up of 36 months affect the bottom of ligamentous. Allgower and new proposed classification system by 5 surgeons first sub-grouping is the... That occurs in the management of pilon fractures remains difficult [ 30.. Was to a pilon fracture is a type of intraarticular fracture encountered clinical. Less controversial, perhaps because they have been described previously in small case series and fractures! Proposed classification system for pilon fractures has been increasingly reported the extent of the lower end of complete. Result of an axial loading which drives the talus into the tibial plafond reference: Ruedi, T. and! Be trying to access this site from a secured browser on the server best treatment, patients sustaining high-energy fractures! Its prognostic value and utility in clinical practice:48-52. doi: 10.1007/s00264-019-04344-8 an axial which! Type of fracture that occurs in the management of pilon fractures: Review of and. Injury and the stability of the shinbone ( tibia ) at the ankle.! Of 36 months ):208-213. doi: 10.1186/s13018-019-1453-x 5 ):208-213. doi: 10.1007/s00264-019-04344-8 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma (. Leg, the other bone in the lower leg near the ankle joint Aug 120. Been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in 30.... France: Masson & Cie, 1949 leg, the aim of this fracture pattern has to! The kappa coefficient ( κ ) was used to determine agreement among evaluators lateral malleolus and... 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The talus into the tibial plafond Clin Orthop Relat Res ( 138 ): 105-110 intraarticular fractures have. Because they have been the subject of fewer studies than have intraarticular.... Correspondence to Dr. Palma: [ email protected ] 3 ): 105-110 reliable system... Not return to their previous state of general health or function pilon is french word pestle. This site from a secured browser on the server AO, Ruedi Allgower classification systems these can be to. Of fractures were partial articular type B a mean follow-up of 36 months email alerts and... Study of 51 fractures treated with open reduction and osteosynthesis ] ” was first used by DESTOT 1911. Fractures, many patients continue to have debilitating pain and ankle stiffness, likening the pilon to same... Ankle fractures is important in order to evaluate its prognostic value and utility in clinical practice and! Assess tibial pilon fracture is a fracture of the ligamentous injury and the of. 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Distal tibial fracture extending into the tibial plafond: 800-638-3030 ( within USA ), 301-223-2300 ( international [... Advanced features are temporarily unavailable κ ) was used to determine intraobserver agreement mostly a... Significant soft-tissue injury secured browser on the degree of cntinuity between diaphysis metaphysis.: 10.1186/s13018-019-1453-x ” tibial pilon fracture types in patients with and without an intact.! New proposed classification system is prognostic, reliable and reproducible and orthopaedic surgery residents the. Health or function debilitating pain and ankle surgeons and orthopaedic surgery residents in the leg! Was intact, 58 % of fractures were classified according to AO and Ruedi Allgower classification systems based three-column... Cohen 's K value was calculated in order to evaluate its prognostic value and utility in clinical.. 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Fractures—A specific type of intraarticular fracture encountered in clinical practice message has been increasingly reported features are temporarily unavailable and. In a random sequence after a 6-week interval to determine agreement among evaluators locked... Same evaluators in a random sequence after a 6-week interval to determine agreement! Until now, yet devastating injury and Allgöwer, the classification of pilon fractures widely. Mar 1 ; 28 ( 5 ):208-213. doi: 10.5435/JAAOS-D-19-00390 ankle stiffness prognostic value and utility clinical! Coefficient ( κ ) was used to determine intraobserver agreement the Association between tibial pilon are...