title: Entrapped posteromedial structures in pilon fractures.
abstract: OBJECTIVE
  To analyze a patient cohort who sustained a tibial pilon fracture and report the incidence of interposed posteromedial soft tissue structures.
  
  
  METHODS
  Retrospective cohort review.
  
  
  METHODS
  Regional Level 1 Trauma Center.
  
  
  METHODS
  About 394 patients with 420 pilon fractures treated between January 2005 and November 2011.
  
  
  METHODS
  Each patient's preoperative radiographs and computed tomography (CT) images were reviewed. The axial and reconstructed images were used in bone and soft tissue windows to identify any posteromedial soft tissue structures incarcerated within the fracture.
  
  
  METHODS
  Medical charts reviewed for the presence of preoperative neurologic deficit, separate posteromedial incision, and whether attending radiology CT interpretation noted the interposed structure.
  
  
  RESULTS
  40 patients with 40 fractures (9.5%) had an entrapped posteromedial structure. The tibialis posterior tendon was interposed in 38/40 fractures (95%) and the posterior tibial neurovascular bundle in 4/40 fractures (10%). Preoperative neurologic deficit occurred in 5/40 patients (12%). A posteromedial incision was used in 11/40 fractures (27%). The attending radiology CT interpretation noted the interposed structure in 8/40 fractures (20%).
  
  
  CONCLUSIONS
  In addition to the osseous injuries, CT imaging can demonstrate the posteromedial soft tissue structures. In our series, the tibialis posterior tendon was commonly incarcerated. In some cases, removal of the entrapped structure(s) may not be possible through the more commonly used anterolateral and anteromedial surgical approaches, and a separate posteromedial exposure may be required. Failure to recognize the presence of an interposed structure could lead to malreduction, impaired tendon function, neurovascular insult, and the need for further surgery.
  
  
  METHODS
  Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Orthopaedic Surgery, Davis Medical Center, University of California, Sacramento, CA; and †Department of Orthopaedic Surgery and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, WA.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: Eastman
authors.forename: Reza
authors.initials: R
authors.lastname: Firoozabadi
authors.forename: Stephen K
authors.initials: SK
authors.lastname: Benirschke
authors.forename: David P
authors.initials: DP
authors.lastname: Barei
authors.forename: Robert P
authors.initials: RP
authors.lastname: Dunbar
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D059348:Peripheral Nerve Injuries / Q000000981:diagnostic imaging / Q000209:etiology; D011859:Radiography; D012189:Retrospective Studies; D017695:Soft Tissue Injuries / Q000000981:diagnostic imaging* / Q000209:etiology; D013708:Tendon Injuries / Q000000981:diagnostic imaging / Q000209:etiology; D013978:Tibial Fractures / Q000150:complications* / Q000000981:diagnostic imaging; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000209:etiology