Introduction: Surgeons treating tibial fractures by the Ilizarov Method are faced with the diagnostic dilemma of determining whether a fracture has united to remove the frame safely.

Methods: Considering frame removal we use three criteria:

Consideration of natural history of the injury – characteristics of the injury and existing knowledge of healing times.

Results: Premature frame removal was identified in 2/106 tibial fractures treated with Ilizarov frames. In both cases subsequent CT scanning identified a healed fibula and stiff non-union of the tibia. In both, original fracture geometry was complex, with fracture lines outwith the planes of radiographic assessment. Timely frame removal in104/106 (98%).

Discussion: In both cases of premature removal the frame was reapplied to achieve union. Premature removal must be balanced against the patient’s desire to have their cumbersome fixator removed at the earliest opportunity.

It is said “It is better to leave a frame on one month too long than to remove it a day too soon”, but this merely emphasises that timing of frame removal remains an art rather than an exact science.

Marsh and Montgomery have previously suggested use of CT scanning to assess union in peri-articular fractures. We recommend that in high energy tibial fractures whose fracture pattern geometry lies outwith the antero-posterior and lateral radiograph views, a CT scan should be considered to detect stiff non-union and avoid premature frame removal.

Introduction: Pilon fractures are severe injuries of the distal tibia usually characterised by severe soft tissue “hit” in addition to the underlying fracture. Historically, plating techniques have led to a significant rate of serious complications. This study describes our early experience treating such injuries by the Ilizarov Method.

Methods: 30 patients were prospectively identified and followed up beyond frame removal clinically and by case note review. Fractures classified according to AO. Bony union evaluated radiologically and clinically – remodelling of bone trabeculae on two radiographs and ability to weight bear without discomfort/walking aids on a dynamised frame.

Results:

Mean age 45.3 years, male: female = 26:4.

Seven fractures were Grade 3 open.

Patients were grouped as follows:

43-A .1/.2/.3 = 1/2/2

Two patients with 43-C.3 fracture had additional corticotomy for bone loss.

Twenty-nine pilons united.

Overall mean time to union was 20 weeks.

Times to union (weeks):

Group 43-A: - median = 20, mean = 21.

24 patients had no major complications. One Grade 3B open 43-C.3 fracture had deep sepsis prior to transfer to our unit which could not be eradicated – this led to transtibial amputation. Two patients had valgus mal-union and One had stiff nonunion requiring a second frame. Eleven patients experienced superficial pinsite infection that resolved with oral antibiotic therapy. Two deep pinsite infections were eradicated by overdrilling.

Conclusion: The Ilizarov method offers safe and reliable healing for distal tibial pilon fractures in mean 20 weeks, with low levels of serious complications despite the severity of the initial injuries.

Fractures of the occipital condyle are rare. Their prompt diagnosis is crucial since there may be associated cranial nerve palsies and cervical spinal instability. The fracture is often not visible on a plain radiograph. We report the case of a 21-year-old man who sustained an occipital condylar fracture without any associated cranial nerve palsy or further injuries. We have also reviewed the literature on this type of injury, in order to assess the incidence, the mechanism and the association with head and cervical spinal injuries as well as classification systems, options for treatment and outcome.