Pilon Fractures

Pilon Fractures

George S. Gumann

Justin J. Fleming

The opinions of the authors are their private views and are not to be considered as representative of official policy of the U.S. Army Medical Department.

The pilon fracture was first described by Destot (1) in 1911. A pilon fracture involves the distal tibial metaphysis with extension into the ankle joint. These injuries are generally produced by either axially/compressive loading patterns or rotational forces. Some fractures may exhibit elements of both mechanisms. Compressive-type fractures are high-velocity injuries in which the talus impacts the distal portion of the tibia, producing bony comminution, varying degrees of displacement, major articular derangement, and significant soft tissue damage. Due to these factors, the overall prognosis is very problematic. There is usually, but not always, an associated fibular fracture. Rotational forces produce a low-velocity-type injury with a spiral configuration of the distal tibia, which may or may not enter the ankle joint. This results in less complex articular injury. The subsequent soft tissue injury is generally less morbid and typically allows for a more favorable prognosis. Pilon fractures represent less than 1% of all lower extremity fractures and 1% to 10% of all tibial fractures (2,3). Approximately 20% to 25% of these injuries are open. One-third are associated with other injuries. Common mechanisms of injury include motor vehicle accidents, falls from heights, and skiing accidents.

Some fracture patterns are dictated by the position of the foot at the time of injury. If the foot is dorsiflexed, the anterior portion of the talar dome will impact and fracture the anterior aspect of the tibial plafond. If the foot is plantarflexed, then the posterior aspect of the tibial plafond will be fractured. A neutrally positioned foot will cause a Y-shaped fracture resulting in anterior and posterior fragments. An inverted foot will produce fractures more on the medial aspect of the tibia, while an everted foot will involve the lateral aspect (4). Pilon fractures are complex injuries, and successful treatment requires great expertise.


Historically, the classification system advocated by Ruedi and Allgower (5) has been commonly used to describe pilon fractures. There are three fracture types. Type I is a fracture of the distal tibia without significant displacement. Type II is a fracture of the distal tibia with significant displacement. Type III is a fracture of the distal tibia with severe comminution, significant displacement, and loss of the weight-bearing portion of the tibial plafond (Fig. 110.1). More recently, the AO/OTA classification of pilon fractures has been utilized. Type A is extra-articular, type B is partially articular, and type C is completely articular. There are subtypes of each classification based on increasing complexity of the articular and metaphyseal components (Fig. 110.2) (4).

Lauge-Hansen (6) also attempted to describe this fracture pattern with his classification of pronation-dorsiflexion injuries. They were divided into four stages. Stage I is a fracture of the medial malleolus. Stage II is a fracture of the anterior aspect of the distal tibia. Stage III is a fracture of the fibula. Stage IV is a transverse fracture of the distal tibia.

Kellam and Waddell (7) suggested two distinct fracture patterns that were correlated to the mechanism of injury. Type A was a fracture with two or more large tibial articular fragments, minimal or no anterior comminution, and usually a transverse or short oblique fracture of the fibula above the plafond. This fracture pattern is produced by a primary rotation force with minimal axial compression. Type B was a compressive fracture demonstrating multiple tibial fragments, a narrowed ankle joint, significant anterior tibial comminution, and superior migration of the talus. The injury is caused by a severe axial compression force but is not always associated with a fibular fracture. Kellam and Waddell (7) note that the rotation injury has less soft tissue compromise and a better prognosis. Tile (8) agrees with this classification but identifies an axial compression fracture, a shear (tension) fracture, and a combined pattern.

Ovadia and Beals (9) have proposed another classification system. This classification has five categories based on the degree of comminution and displacement. Type I fractures enter the ankle joint but are nondisplaced. Type II fractures enter the ankle joint and are minimally displaced. Type III fractures enter the ankle joint and are moderately displaced with several large fragments. Type IV fractures are also moderately displaced, intra-articular, and associated with large metaphyseal defects. Type V fractures have severe comminution of the distal tibial metaphysis and the articular surface.


The assessment of these injuries typically begins in the emergency room. It may be an isolated injury or a component in the polytrauma patient. The examination must be complete and systemic as concomitant contra- and ipsilateral injuries can occur. Appropriate communication with other services (trauma, vascular surgery, plastics, orthopaedics) may be essential to successful management. There may or may not be gross deformity of the distal leg and ankle. Examine the soft tissue envelop for the possibility of an open fracture or any dermal lesions. There will be diffuse tenderness involving the ankle and distal tibia. Initial and possibly interval neurovascular evaluation is required. The compression-type pilon fractures tend to produce significant soft tissue edema and have the potential to develop fracture blisters in 24 to 72 hours.


Radiographs of the foot, ankle, and leg should be obtained. Gross deformity, degree of tibial articular and metaphyseal comminution, and articular displacement will be demonstrated.
The presence, level, and complexity of the fibular fracture will be noted if present. Contralateral films of the ankle may be utilized at the time of definitive surgery as a template for reconstruction if necessary.

Figure 110.1 Ruedi and Allgower classification of pilon fractures.

Acute CT scanning of axial compression pilon fractures typically provides little value. CT evaluation following application of a spanning external fixator is more informative because of the gross reduction in fracture alignment. However, it may be beneficial in determining articular involvement of distal tibial fractures that appear extra-articular radiographically, in simple fractures with little displacement or in rotational pilon fractures.

Jul 26, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Pilon Fractures
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