The commonest avoidable disaster in pilon and distal tibial fractures is definitive fixation through an envelope that was not ready. Fracture blisters, a shiny tense dorsum, absent skin wrinkles: none of those is a reason to proceed carefully, they are reasons not to proceed.
Span, elevate, and wait for the wrinkle sign. A temporary spanning external fixator restores length and alignment, lets the swelling settle, and buys the seven to fourteen days that turn a high-risk incision into a routine one. Take the CT after the frame is on, because reduction to length makes the articular map far easier to read and to plan from.
When you do operate, respect the incision spacing you planned on that CT, and if two approaches are needed, keep the bridge wide. A malunion can be corrected later. A deep infection over subcutaneous tibia often cannot.
- Check for skin wrinkles before listing; no wrinkles, no definitive fixation.
- Apply a spanning external fixator early rather than waiting in a backslab.
- Take the planning CT after the frame is applied, not before.
- Plan and mark incisions on the CT, keeping any skin bridge as wide as the plan allows.
- Document the soft-tissue state at each review; it is the record that justifies the delay.
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