What Is Pilon Fracture

  • Raza Siddique Master's degree, Health Information/Medical Records Administration/Administrator, Swansea University, UK
  • Jialu Li Master of Science in Language Sciences (Neuroscience) UCL

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Introduction 

Pilon fractures are severe fractures involving the distal tibia near the ankle joint.1 More specifically, they occur at the tibial plafond, the weight-bearing surface of the distal tibia where it articulates with the talus bone of the ankle.2 Pilon comes from the French word “pestle”, describing the pistoning force on the tibial plafond during trauma.3 These complex fractures often involve both vertical splitting of the articular surface as well as horizontal cleavage lines.4 

Pilon fractures result from high-energy axial trauma, such as falls from height or motor vehicle collisions, where the talus is driven up against the tibia transmitting tremendous force to the distal end.5 They are typically intra-articular, extending into the ankle joint, and are highly unstable.2 Associated extensive soft tissue damage is common. Prompt, specialised surgical treatment is required to restore the complex anatomy and achieve good outcomes. However, complications like post-traumatic arthritis are not uncommon.3

Causes

Pilon fractures typically result from high-energy trauma or an axial load directed upward through the ankle joint.6 Falling from a height and motor vehicle accidents are common mechanisms, where the talus is violently pushed against the tibial plafond.7 The forceful impact splits the distal tibia both vertically and horizontally into the ankle joint.8 Studies show over 80% of these fractures occur due to motor vehicle collisions, falls, or crush injuries.2

Osteoporotic bone is also at higher risk for Pilon fractures due to compromised bone density and strength.9 Elderly patients can sustain these fractures from lower velocity mechanisms like trips and falls compared to younger patients.4 Certain occupational and recreational activities involving jumping or landing can generate sufficient axial loads to also cause Pilon fractures.10 However, high-energy trauma remains the predominant cause in younger, healthy patients. Understanding the various injury mechanisms provides insight into the tremendous forces absorbed by the tibia during Pilon fractures.

Classification

Several classification systems have been developed to categorize Pilon fractures based on the location and extent of tibial articular surface involvement. The most widely utilized is the Müller AO classification.11 Type A fractures are extra-articular, not involving the ankle joint surface. Type B fractures are partial articular, with some of the weight-bearing surface intact. Type C fractures are complete articular, with no contact between fragments.12

The Rüedi-Allgöwer classification further divides type C fractures into 3 subtypes based on the amount of articular surface affected.4 Type 1 involves the anterior rim, type 2 the posterior rim, and type 3 is comminuted involving the entire plafond.2 The AO group also proposed a 3-part categorization of Pilon fractures as simple (unimonocortical), complex (multifragmentary articular), and meta or epiphyseal (involving the tibial shaft).13

Overall, understanding the fracture pattern based on articulation involvement helps guide appropriate surgical planning and predicts prognosis. However, significant variability exists and surgeons emphasize the importance of individually assessing each fracture’s complexity.12

Symptoms

Patients with Pilon fractures typically experience immediate, severe pain and swelling around the ankle after sustaining injury.14 Ability to bear weight is lost due to the unstable, displaced fracture fragments.15 Significant bruising, tenderness, and deformity may be apparent on examination as blood fills the tissue planes around the ankle joint.2 Palpation often elicits crepitus between fracture ends. The abnormal shape and width of the ankle mortise are concerning for disruption of the anatomy.3

Associated soft tissue damage results in additional swelling and compromised skin integrity which can pose healing challenges.16 Neurovascular injury should be assessed by examining distal pulses, sensation, and motor function. Traumatic arthritic changes and stiffness later cause chronic pain and impaired ankle mobility.5 Obtaining a detailed history of the injury mechanism and carefully documenting symptoms and physical findings allows proper classification and guides appropriate workup and treatment.

Diagnosing

A thorough history, physical exam, and appropriate imaging studies are required to confirm the diagnosis of a Pilon fracture and guide management.4 Physical examination assesses anatomy disruption, neurovascular status, and soft tissue condition which can significantly impact treatment (2). Anteroposterior, lateral, and mortise radiographic views of the ankle evaluate fracture pattern, displacement, comminution, and joint congruity.3

Due to the complex, often underestimated nature of these injuries on plain films, CT scanning is routinely performed for complete characterization and surgical planning.17 CT images allow assessment of articular surface involvement, fracture classification, and choice of approach. MRI can also evaluate the integrity of ligaments, menisci, and cartilage, as well as detect any osteochondral lesions in non-displaced fragments that might obscure on CT.18

Early recognition through meticulous diagnostic workup is key, as delayed treatment of unstable Pilon fractures results in higher rates of complications.19 A stepwise approach helps determine the optimal timing and type of surgical stabilisation required.

Treatment

Treatment of Pilon fractures aims to restore articular congruity and stabilize fracture fragments using surgical fixation techniques.4 For minimally displaced fractures with intact cortical contact, nonoperative management in a cast may be trailed initially.2 However, surgery is required for most displaced Pilon fractures to achieve good outcomes and prevent complications like post-traumatic arthritis.3

Open reduction and internal plate-and-screw fixation is the standard treatment for displaced Pilon fractures.20 This involves anatomic realignment of articular surface and rigid fixation using plates and screws through an open incision. Bone grafting may fill defects. Staged procedures are often utilised - external fixation applied first to stabilise, followed by definitive internal fixation once soft tissue swelling subsides.21 Less invasive surgical techniques allow some Pilon fractures to be plated through small incisions using fluoroscopic guidance.12

Postoperatively, non-weight bearing cast immobilisation for 6-12 weeks allows soft tissue healing and fracture union before gradually increasing weight bearing.3 Physical therapy thereafter is critical to regaining ankle mobility and strength. Chronic stiffness may require therapy modalities like manual therapy, ultrasound, and dynamic splinting.22 Good surgical technique and careful postoperative management enables recovery of function in most cases. However, outcomes correlate significantly with the severity of initial soft tissue injury.

Complications

Pilon fractures often result in significant complications both from the initial traumatic injury and as sequelae of treatment. Early complications include soft tissue necrosis, infection, and wound healing problems which can occur in 10-20% of cases.23 Significant initial displacement and fracture comminution leads to more soft tissue trauma which poses challenges to surgical repair and rehabilitation.3

Longer-term complications include malunion with articular incongruity, delayed unions or non-union, post-traumatic arthritis, and chronic pain. Malunions with even 1-2mm of articular displacement alter weight distribution and frequently progress to painful traumatic arthritis.8 Rates of post-traumatic arthritis have been reported up to 80% after Pilon fractures, often requiring late arthrodesis or arthroplasty.5 Chronic ankle stiffness and loss of range of motion is also very common after immobilisation and internal fixation.24  

Surgical treatment can introduce complications like hardware failure requiring additional surgery.23 Refracture after hardware removal has also been reported, necessitating re-fixation.25 Careful surgical technique and patient compliance with rehabilitation are key to reducing adverse outcomes after Pilon fractures. However, some loss of function is not uncommon given the severity of the initial injury.

Summary

Pilon fractures are severe, challenging fractures of the distal tibia involving its weight-bearing articular surface. They result from high-energy axial trauma like falls or traffic accidents which transmit tremendous forces to the ankle.4 Meticulous diagnostic evaluation includes physical, radiographic, and CT examination to fully characterize these complex fractures.2 The Müller AO system classifies Pilon fractures based on the degree of articular involvement and comminution.

Urgent surgical management is required for displaced, unstable Pilon fractures to restore anatomy and achieve good outcomes. This typically involves staged external fixation followed by open reduction and internal plate-and-screw fixation once soft tissue swelling subsides.24 Early complications like wound issues are not uncommon given the magnitude of the injury. Long-term, malunions, arthritis, stiffness, and pain are problematic sequelae.16

A thoughtful, patient-specific approach and precise technique aims to minimise adverse events after Pilon fractures. However, some functional impairment may persist due to the severity of the initial injury. Close follow-up and graduated rehabilitation help patients regain optimal ankle motion and strength after treatment. Protecting the joint from excessive loading and overweight can stave off post-traumatic arthritis.26 Further research on surgical constructs and techniques may continue improving Pilon fracture outcomes.

In summary, while challenging injuries associated with complications, modern fixation methods and structured rehabilitation enable many patients to ambulate and resume daily activities after a Pilon fracture. However, recovery of pre-injury function level is not always achievable.

References

  • Apostolides M, Morcos Z, Mott A, Lewis C. Comparison of surgical treatment methods in patients with closed tibia pilon fractures: A systematic review and meta-analysis of clinical and functional outcomes. Int J Orthop Sci. 2020 Jul 1;6:161–70. 
  • Topliss CJ, Jackson M, Atkins RM. Anatomy of pilon fractures of the distal tibia. J Bone Joint Surg Br. 2005 May 1;87-B(5):692–7. 
  • McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992 Jan 1;6(2):195–200. 
  • Rüedi TP, Allgöwer M. The Operative Treatment of Intra-articular Fractures of the Lower End of the Tibia. Clin Orthop Relat Res. 1979 Feb;(138):105. 
  • Dillin L, Slabaugh P. Delayed Wound Healing, Infection, and Nonunion following Open Reduction and Internal Fixation of Tibial Plafond Fractures. J Trauma Acute Care Surg. 1986 Dec;26(12):1116. 
  • Patel S, Aggarwal S, Jindal K, Kumar V, Sharma S. Outcomes and complications of the INFIX technique for unstable pelvic ring injuries with high-velocity trauma: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2022 May 1;142(5):787–803. 
  • Mauffrey C, VASARiO G, BATTiSTOn B, LEwiS C, BEAzLEY J, SELiGSOn D. Tibial pilon fractures : A review of incidence, diagnosis, treatment, and complications. 2011;77. 
  • Watson JT, Moed BR, Karges DE, Cramer KE. Pilon Fractures: Treatment Protocol Based on Severity of Soft Tissue Injury. Clin Orthop Relat Res. 2000 Jun;375:78. 
  • Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged Management of High-Energy Proximal Tibia Fractures (OTA Types 41): The Results of a Prospective, Standardized Protocol. J Orthop Trauma. 2005 Aug;19(7):448. 
  • Stella M, Santolini E, Sanguineti F, Felli L, Vicenti G, Bizzoca D, et al. Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review. Injury. 2019 Jul 1;50:S57–64.
  • Müller ME, Nazarian S, Koch P. Classification AO des fractures: les os longs. Springer-Verlag; 1987. 
  • Borens O, Kloen P, Richmond J, Roederer G, Levine DS, Helfet DL. Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases. Arch Orthop Trauma Surg. 2009 May 1;129(5):649–59. 
  • Tile M. The rationale of operative fracture care. Berlin: Springer-Verlag; 1987. 
  • Bernstein J, Adler LM, Blank JE, Dalsey RM, Williams GR, Iannotti JP. Evaluation of the Neer System of Classification of Proximal Humeral Fractures with Computerized Tomographic Scans and Plain Radiographs*. JBJS. 1996 Sep;78(9):1371. 
  • Kayali C, Agus H, Turgut A. Successful results of minimally invasive surgery for comminuted supracondylar femoral fractures with LISS: comparative study of multiply injured and isolated femoral fractures. J Orthop Sci. 2007 Sep 1;12(5):458–65. 
  • Wyrsch B, Mcferran MA, Mcandrew M, Limbird TJ, Harper MC, Johnson KD, et al. Operative Treatment of Fractures of the Tibial Plafond. A Randomized, Prospective Study*. JBJS. 1996 Nov;78(11):1646. 
  • Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018 Dec 1;49(12):2252–63. 
  • van Dreumel RLM, van Wunnik BPW, Janssen L, Simons PCG, Janzing HMJ. Mid- to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury. 2015 Aug 1;46(8):1608–12. 
  • Vallier HA, Cureton BA, Patterson BM. Factors Influencing Functional Outcomes After Distal Tibia Shaft Fractures. J Orthop Trauma. 2012 Mar;26(3):178. 
  • Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia—Results in 20 patients. Injury. 2006 Sep 1;37(9):877–87. 
  • Patterson MJ, Cole JD. Two-Staged Delayed Open Reduction and Internal Fixation of Severe Pilon Fractures. J Orthop Trauma. 1999 Feb;13(2):85. 
  • Mair O, Pflüger P, Hoffeld K, Braun KF, Kirchhoff C, Biberthaler P, et al. Management of Pilon Fractures—Current Concepts. Front Surg [Internet]. 2021 [cited 2023 Nov 16];8. Available from: https://www.frontiersin.org/articles/10.3389/fsurg.2021.764232
  • Boraiah S, Kemp TJ, Erwteman A, Lucas PA, Asprinio DE. Outcome Following Open Reduction and Internal Fixation of Open Pilon Fractures. JBJS. 2010 Feb;92(2):346. 
  • Sirkin M, Sanders R. THE TREATMENT OF PILON FRACTURES. Orthop Clin North Am. 2001 Jan 1;32(1):91–102. 
  • Bear J, Rollick N, Helfet D. Evolution in Management of Tibial Pilon Fractures. Curr Rev Musculoskelet Med. 2018 Dec 1;11(4):537–45. 
  • Pollak AN, McCarthy ML, Bess RS, Agel J, Swiontkowski MF. Outcomes After Treatment of High-Energy Tibial Plafond Fractures. JBJS. 2003 Oct;85(10):1893. 

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Raza Siddique

Master's degree, Health Information/Medical Records Administration/Administrator, Swansea University

As a dentistry professional pursuing a Master's in Health Informatics, I leverage expertise in oral healthcare and a passion for technology to advance innovations in digital health. My background includes providing compassionate, high-quality dental care and building strong patient relationships. Currently, I am developing skills in data analytics, system implementation, and workflow optimization to improve health outcomes. I have a passion for research writing and synthesizing complex health information into digestible resources for various audiences. My goal is to utilize my robust clinical knowledge and evolving tech capabilities to enhance interoperability, data security, and care coordination throughout the healthcare ecosystem. I stay attuned to emerging trends in digital health to identify opportunities to increase accessibility, engagement, and value-based care for diverse populations.

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