A Pilon fracture is a specific type of break (aka fracture) of the ankle joint. It refers to a fracture of the tibia at the joint surface (aka intra-articular). A pilon fracture typically occurs from a high energy injury such as a fall from a height or motor vehicle collision and often have multiple fragments of bone called comminution. The high energy nature as well as the involvement of the joint surface makes a pilon fracture a more severe injury with higher complications then an ankle fracture caused by a twisting injury.
Pilon Fracture Symptoms and Anatomy
The ankle joint is made up of three bones, the tibia (the shin bone which supports most of the body weight), the fibula (the smaller shin bone), and the talus. While a pilon fracture specifically refers to the weight bearing portion of the tibia, it often occurs together with a fracture of the fibula. The higher energy injury typically causes more severe injury to the skin around the ankle including open fractures (exposed bone). These fractures may also occur in conjunction with injuries to other bones, abdomen or head.
- Inability to bear weight
- Deformity of the ankle
- Skin wounds, including exposed bone
- Swelling, bruising, blisters of the skin due to the swelling
- Nerve and blood vessel injury particularly in open wounds
Pilon Fracture Treatment Options
These injuries often require immediate attention at a hospital. Emergency physicians will assess for other injuries to the head, spine, chest and abdomen. The orthopedic surgeon will assess the leg and ankle in addition to evaluate for other injuries to spine, pelvis or extremities. The doctor will examine for wounds and swelling, blood flow to the foot, as well as the sensation and movement of your toes. Once a complete exam is performed, the doctor will order and review x-rays and sometimes a CT scan to plan for surgery. If the fracture pieces are not out of alignment (nondisplaced, then nonoperative treatment is an option. However, these injuries often require surgery to improve alignment and provide stability for better healing.
Pilon Fracture Surgery
Surgical treatment is often in stages due to the degree of soft tissue injury, swelling and other associated injuries to the head, chest and abdomen.
An external fixator is typically the first stage in a severe injury with a lot of swelling and soft tissue injury. The doctor will make small incisions and place metal pins into the bone, away from the injury site. These pins are connected by bars outside of the skin to keep the joint and fractures stable and improve overall alignment while the swelling and soft tissue injury improves. The external fixator could be placed very quickly in the case that other injuries to the head, chest or abdomen are more severe and more life threatening.
Open Reduction and Internal Fixation
Once the swelling has improved (typically in 1-2 weeks), the definitive surgery takes place. One or more incision will be made to restore the fracture fragments to the proper alignment and restore the joint surface. The fracture fragments will be held in place with metal plates and screws.
Pilon Fracture Complications
The severity of these types of fractures leads to a higher rate of complications. These include wound problems and infection. The bones may not heal, this is called nonunion, or they may heal in a bad position, this is called malunion. Long term complications include stiffness of the ankle joint and post-traumatic arthritis which may require additional surgery.