Introduction

Pilon fractures are routinely due to high-energy mechanisms secondary to axial loading of the talus into the tibial plafond. They had been associated with unacceptably high rates of complications prior to the implementation of staged management. Although this has changed, these fractures remain challenging and rigorous application of treatment principles is imperative to ensure optimal outcomes.

I. Preoperative

1. 
   

   History and physical examination

   
   
   
   
   1. 
      

      Due to the high-energy mechanism of these injuries, patients should be evaluated according to standard advanced trauma life support (ATLS) protocol.

      
      
   2. 
      

      Fall from height mechanism is often associated with calcaneal and thoracolumbar spine fractures.

      
      
   3. 
      

      Vascular and neurological injuries are commonly associated with pilon fractures and a thorough examination should be documented.

      
      
   4. 
      

      Dysvascular limbs that do not recover following initial reduction should be investigated with vascular surgery according to local protocols.

   
   
2. 
   

   Anatomy

   
   
   
   
   1. 
      

      Axial compression with foot in dorsiflexion leads to comminution of the anterior aspect of the plafond.

      
      
   2. 
      

      Axial loading with the foot in plantar flexion causes injury to the posterior aspect of the plafond.

      
      
   3. 
      

      Injury to lateral and medial aspects of plafond are associated with the hindfoot being abducted and adducted, respectively. The foot being in a neutral position results in injury to the anterior and posterior regions.

      
      
   4. 
      

      Pilon fractures occur in a typical fracture pattern. Although variations exist, most fractures are comprised of an anterolateral fragment (Chaput’s), a posterolateral fragment (Volkmann’s), a medial malleolus fragment, and a central die-punch region (▶ Fig. 42.1 ).

      

   
   
3. 
   

   Imaging

   
   
   
   
   1. 
      

      High-quality orthogonal X-rays of the ankle should be obtained.

      
      
   2. 
      

      As these are generally high-energy fractures, foot- and full-length tibia X-rays should also be obtained.

      
      
   3. 
      

      Postreduction X-rays to determine quality of reduction.

      
      
   4. 
      

      CT scans are generally obtained following external fixation; they can be obtained prior in certain situations (where partial or acute definitive fixation is considered).

      
      
   5. 
      

      CT scan should be used to evaluate articular fragments, location of fracture lines, degree of impaction, associated injures (tendon sheath avulsions, kissing lesions on talus, other associated fractured bones), and fibular fracture.

      
      
   6. 
      

      Axial cuts are most useful for surgical planning and fragment evaluation. Special attention should be given to assessing for entrapped posteromedial structures within fractures, such as posterior tibial tendon or the posterior tibial neurovascular bundle.

      
      
   7. 
      

      Coronal and sagittal reformats should be analyzed to aid in preoperative planning and assess for areas of impaction.

      
      
   8. 
      

      If the fibula was fixed during initial stage of management, length can be assessed on coronal CT.

   
   
4. 
   

   Classification

   
   
   
   
   1. 
      

      AO/OTA classification is most useful for pilon fracture nomenclature: A type is extra-articular, B type is partial articular, and C type is complete articular.

      
      

      Degree of comminution will dictate severity of injury (i.e., 43C1 vs. 43C3).

II. Treatment

1. 
   

   Initial management

   
   
   
   
   1. 
      

      Fractures should be reduced in the emergency department and placed into a bulky splint.

      
      
   2. 
      

      Soft-tissue swelling can be surprisingly severe. Blisters can be covered with nonadherent dressings.

      
      
   3. 
      

      Most pilon fractures will undergo staged management with external fixation initially, followed by definitive fixation when soft-tissue swelling improves. Recent evidence has shown equivalent results with acute (< 24 hours) definitive fixation of pilon fractures; however, results have not been widely replicated.

      
      
   4. 
      

      Low-energy pilon fractures or variants (geriatric/osteoporotic) may be amenable to primary fixation.

      
      
   5. 
      

      External fixation of pilon fractures should focus on restoring length, alignment, and rotation.

      
      
   6. 
      

      Ligamentotaxis, strategically placed Schanz pins, and appropriate distraction vectors will help achieve reduction.

      
      
   7. 
      

      Associated fibula fractures can undergo ORIF in this initial setting if soft tissues permit. Fibula fixation should not take place during the initial surgery under the following circumstances:

      
      
      
      
      1. 
         

         Complex fractures when malreduction can occur.

         
         
      2. 
         

         The definitive fixation will be performed by a different surgeon.

   
   
2. 
   

   Definitive management

   
   
   
   
   1. 
      

      Nonoperative management of pilon fractures is uncommon except for nondisplaced fractures (< 2 mm displacement with normal length and alignment) and in patients with prohibitive medical comorbidities or nonambulating patients.

      
      
   2. 
      

      Historically, definitive management should be delayed until soft-tissue swelling has subsided (positive wrinkle sign) and fracture blisters have sufficiently re-epithelialized; however, some studies have shown early definitive fixation may yield equivalent outcomes for select patients.

      
      
   3. 
      

      Because pilon fractures involve the articular surface, open reduction and internal fixation (ORIF) is the mainstay of treatment.

      
      
   4. 
      

      ORIF of pilon fractures consists of four major points:

      
      
      
      
      1. 
         

         Anatomic reduction of the articular surface.

         
         
      2. 
         

         Solid fixation of the articular segment to the diaphysis.

         
         
      3. 
         

         Fixation of the fibular fracture.

         
         
      4. 
         

         Potential grafting or filling with bone substitutes of metaphyseal bone defects/loss.

      
      
   5. 
      

      Most fractures are treated with plate and screw fixation; however, some type A and C1 (simple articular) fractures may be amenable to intramedullary fixation.

      
      
   6. 
      

      There is continued controversy regarding definitive management with external fixation and limited ORIF versus formal ORIF with direct visualization of the articular surface and key fracture elements. The following apply to external fixation and limited ORIF:

      
      
      
      
      1. 
         

         Typically can be done earlier than formal ORIF.

         
         
      2. 
         

         The fibula is typically not fixed as this has been shown to have a higher complication rate with no clinical benefit.

         
         
      3. 
         

         Both joint spanning frames and ring fixators (without spanning the joint) can be used. If a ring fixator is used, many times a temporary “foot plate” will be added initially and then removed 4 to 6 weeks post-op to allow early ankle range of motion.

         
         
      4. 
         

         External fixation and limited ORIF may be a better option for grossly contaminated open injuries or injuries with significant soft-tissue loss.

   
   
3. 
   

   Surgical approaches

   
   
   
   
   1. 
      

      Several approaches are described to treat pilon fractures. Often a combination of these approaches is needed to adequately address these fractures (▶ Fig. 42.2 ).

      

      
      
   2. 
      

      Anteromedial:

      
      
      
      
      1. 
         

         Medial to the tibialis anterior and lateral to the tribal crest proximal to the ankle joint.

         
         
      2. 
         

         The incision is curved at the joint toward the tip of the medial malleolus.

         
         
      3. 
         

         Allows good visualization of the joint and medial gutter (▶ Fig. 42.3 ).

         

      
      
   3. 
      

      Anterolateral:

      
      
      
      
      1. 
         

         Lateral to the peroneus tertius/extensor digitorum communis and medial to the peroneal muscles in line with the fourth ray of the foot.

         
         
      2. 
         

         Offers great visualization of the lateral fragments.

      
      
   4. 
      

      Posteromedial:

      
      
      
      
      1. 
         

         Between the tibialis posterior tendon and flexor digitorum communis or between the flexor hallucis longus and the flexor digitorum communis.

         
         
      2. 
         

         Permits good visualization and direct fixation of the medial posterior malleolus.

      
      
   5. 
      

      Posterolateral:

      
      
      
      
      1. 
         

         Uses the interval between the peroneal tendons and the flexor hallucis longus.

         
         
      2. 
         

         Facilitates exposure of the fibula and the posterior malleolus for buttress plate application.

      
      
   6. 
      

      Direct medial:

      
      
      
      
      1. 
         

         Between the tibialis anterior and posterior tendons along the medial face of the tibia.

         
         
      2. 
         

         Less commonly used due to soft-tissue concerns.

         
         
      3. 
         

         It can be used for minimally invasive plating of extra-articular fractures.

   
   
4. 
   

   Fixation techniques

   
   
   
   
   1. 
      

      Several strategies can be used to achieve this; however, two principles are frequently used for C-type fractures:

      
      
      
      
      1. 
         

         Convert a C-type to a B-type fracture:

         
         
         
         
         • 
           

           i. This involves fixation of a specific fragment (medial malleolus, Chaput’s, or Volkmann’s) to the intact diaphysis.

           
           
         • 
           

           ii. Build back to the intact segment.

           
           
         • 
           

           iii. Most useful for fractures with little or no metaphyseal comminution.

         
         
      2. 
         

         Convert a C-type to an A-type fracture:

         
         
         
         
         • 
           

           i. Anatomically reduce all joint fragments together before fixing them.

           
           
         • 
           

           ii. This strategy can be employed when there is significant metaphyseal comminution with or without articular comminution.

           
           
         • 
           

           iii. Most common fixation constructs include an anterolateral plate with a component of medial fixation (screws or plate fixation; ▶ Fig. 42.4a, b ).

           

      
      
   2. 
      

      External fixators can be kept on for 6 weeks following fixation to neutralize deforming forces, help maintain length, and protect the articular reduction in the following circumstances:

      
      
      
      
      1. 
         

         Severely comminuted fractures.

         
         
      2. 
         

         Severe soft-tissue injury.

         
         
      3. 
         

         Patients with osteopenia.

      
      
   3. 
      

      Definitive external fixation with a ring fixator, with or without limited internal fixation, might be considered for open pilon fractures, compartment syndrome, or patients with poor healing potential due to high risk of soft-tissue complications.

   
   
5. 
   

   Complications

   
   
   
   
   1. 
      

      Infection rate is approximately 5 to 15% for closed fractures.

      
      
   2. 
      

      Wound complication/dehiscence is relatively common and seen in up to 30% of patients. Often these can be treated with simple dressing changes but occasionally require return to the operating room for debridement.

      
      
   3. 
      

      Post-traumatic arthritis is common, but patients may not require further surgery for several years.

      
      
      
      
      1. 
         

         Conservative treatment options include bracing, nonsteroidal anti-inflammatory medication, acetaminophen, and cortisone injection.

         
         
      2. 
         

         Reconstructive options for symptomatic post-traumatic arthritis that has failed conservative measures include fusion (most common), arthroplasty (rarely performed), and amputation in severe cases.

   
   
6. 
   

   Rehabilitation

   
   
   
   
   1. 
      

      Patients are placed in a splint for 2 to 3 weeks for soft-tissue rest. Sutures are removed at this time.

      
      
   2. 
      

      Patients are kept non–weight bearing for 8 to 12 weeks and then progressed to full weight bearing.

      
      
   3. 
      

      Gentle range of motion exercises of the ankle can be started once the wound has healed.

   
   
7. 
   

   Outcomes

   
   
   
   
   1. 
      

      Open fractures lead to higher complication rates and worse outcomes.

      
      
   2. 
      

      Staged management of most pilon fractures with meticulous soft-tissue management is vital in improving outcomes.

      
      
   3. 
      

      Nonoperative management with displaced intra-articular fractures lead to poor outcomes

      
      
   4. 
      

      Quality of reduction and ankle range of motion correlate with quality of life (QOL) and Olerud–Molander ankle score.