Orthopedic Research and Reviews

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Pilon Fractures: Challenges and Solutions

Bishoy N Saad, John M Yingling, Frank A Liporace & Richard S Yoon

To cite this article: Bishoy N Saad, John M Yingling, Frank A Liporace & Richard S Yoon (2019)
Pilon Fractures: Challenges and Solutions, Orthopedic Research and Reviews, , 149-157, DOI:
10.2147/ORR.S170956

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Pilon Fractures: Challenges and Solutions

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Orthopedic Research and Reviews

Bishoy N Saad Abstract: Pilon fractures include a wide range of complexity. The timing and type of
John M Yingling definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture.
Frank A Liporace One should have a low threshold for staged protocols and delayed definitive fixation to avoid
Richard S Yoon complications. Proper radiographs and advanced imaging should be obtained for an exacting
diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic
Division of Orthopaedic Trauma and
restoration of the articular surface, length, rotation, and axial alignment with stable fixation
Complex Adult Reconstruction,
Department of Orthopaedic Surgery, to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous
Jersey City Medical Center - articular fixation for simple or extra-articular patterns provide good results with little soft
RWJBarnabas Health, Jersey City, NJ,
USA tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can
help mitigate some concerns with soft tissue compromise while obtaining good articular
alignment. Locking or conventional plating with lag screw fixation is used for complex
Video abstract articular injuries with or without fibular fixation. External fixators are generally used for
temporizing measures but can be utilized as definitive fixation when indicated. There is a role
for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with
poor healing potential. This article outlines the diagnostic workup and treatment of these
vexing injuries with solutions to challenges that arise.
Keywords: pilon fracture, plafond fracture, intra-articular ankle fractures, distal tibia
fracture, AO/OTA 43A-C

Introduction
Point your SmartPhone at the code above. If you have a First described by French radiologist Destot in 1911, pilon fractures are defined as
QR code reader the video abstract will appear. Or use:
https://youtu.be/T5A-eK3tmnU injuries that involve the articular weight-bearing surface of the distal tibia. The term
“pilon” is derived from the French language, meaning pestle, resembling a pharma-
cist’s pestle when paralleled to the distal tibial metaphysis. Later termed “plafond”
meaning “ceiling” in the French language, equating the distal tibial articular surface
as the ceiling of the ankle joint. These injuries compile <1% of all lower extremity
fractures and achieving good clinical outcomes is both challenging and complex.1
Compared to the fractures originally described and treated by Rüedi and Allgöwer,
pilon fractures globally represent higher-energy mechanisms that often involve sub-
stantial articular impaction and severe soft tissue injury due to an axial load rather
than the relatively low energy rotational mechanism originally studied.2–7 The
Correspondence: Richard S Yoon
Division of Orthopaedic Trauma and importance of addressing all components of the skeletal trauma cannot be overstated.
Complex Adult Reconstruction,
Department of Orthopaedic Surgery, Even after successful treatment of these injuries, complications in the postoperative
Jersey City Medical Center – RWJBarnabas period, such as infection, wound dehiscence, non-union, malunion, and post-trau-
Health, 377 Jersey Ave, Suite 280A, Jersey
City, NJ 07302, USA matic osteoarthritis are difficult to avoid without proper technique.6 Thus, this review
Tel +1 201 716 5850 offers an update to surgical management and treatment of pilon fractures with special
Fax +1 201 915 2424
Email [email protected] considerations taken during the decision-making process.

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Mechanism of Injury and Evaluation of the fibula can provide further information
on the stability of the injury. For example, an intact fibula
Classification Systems
can necessitate medial column instability and varus defor-
Rüedi and Allgöwer were one of the first to describe pilon
mity while the opposite is true when the fibula is
fractures. Their classification was derived from the evalua-
involved.5,10,11
tion of rotational injuries sustained following skiing
The Arbeitsgemeinschaft für Osteosynthesefragen/
accidents.8,9 Three different fracture types based on com-
Orthopedic Trauma Association (AO/OTA) offers a more
minution and displacement of the articular surface were
comprehensive classification system dividing up pilon
proposed. Type I are intra-articular fractures without dis-
fractures into Types A, B, and C with subsequent subtypes
placement, type II are displaced fractures without commi-
(Table 1). Type A are extra-articular fractures, Type B are
nution, and type III are displaced fractures with impaction
partial articular involving a single column, and Type C are
and comminution (Table 1).
complete articular fractures, all with subtypes differen-
While rotational pilon fractures still occur, the vast
tiated on fracture pattern, amount of comminution, and
majority are the result of higher-energy mechanisms such
presence or location of impacted articular fragments.
as falls from a great height and motor vehicle accidents.
Likely due to the nature and variability of the multitude
The fracture pattern and soft tissue injury is dictated by the
of possible fracture patterns, this classification is very
positioning of the foot at the time of injury. Typically, the
inclusive and descriptive but shows inconsistent interob-
talus is driven into the plafond during a high-energy axial
server reliability.12–15
load. When the foot is plantar-flexed at the time of injury,
As a result, DeCoster et al classified patients based on
forces are directed into the posterior portion of the articu-
the severity of injury regarding the articular surface, the
lar surface leading to impaction and posterior talar displa- entire fracture pattern, and the quality of the reduction
cement. The opposite is true when the foot is dorsiflexed, after operative fixation. Ninety-four percent of orthopedic
the energy is transmitted through the anterior region. surgeons agreed on ranking the severity of the articular
Neutral foot positioning results in a purely vertical vector surface injury, 89% on fracture pattern and reduction of
engaging the entire articular surface, resulting in both the articular surface, and 88% on the quality of the overall
anterior and posterior column fractures with variable reduction of the injury.16 Therefore, despite disagreement
varus and valgus angulation. When the force is predomi- on the classification of pilon fractures found among ortho-
nantly midline or medial to the ankle, the fracture will pedic surgeons, an interobserver agreement can be found
result in a varus deformity. Likewise, when exerted lateral based on evaluating the severity of injury and quality of
to the center of the ankle, valgus configuration results. the reduction.

Table 1 Classification Systems Initial Evaluation and Treatment

Rüedi and Allgöwer A thorough history and physical exam upon initial pre-
sentation can aid the clinician in dictating treatment.
Type 1 Nondisplaced intra-articular
Comorbidities, such as diabetes and smoking, tend to
Type 2 Displaced without comminution
Type 3 Displaced with comminution
increase the threat of overall complications and need for
revision surgery by 3.8 and 5 times, respectively.17–20
AO/OTA-43
Smokers have an increased risk of wound complications
A – Extra-articular 1-Simple due to microvascular pathology.21 Multidisciplinary care
2-Wedge of these often polytrauma patients is important, as up to
3-Multifragement
57% have associated multisystem injuries.3,4,22–25 Initial
B – Partial articular 1-Split imaging includes anteroposterior, mortise, and lateral
2-Split and depressed radiographs of the ankle. Full-length tibia and fibula
3-Depressed
images further help evaluate possible extension of fracture
C – Complete articular 1-Simple lines into the tibial shaft, coexisting proximal fractures, or
2-Simple articular, multifragmentary prior implants in the extremity.
metaphyseal The incidence of open pilon fractures ranges from 12%
3-Multifragmentary
to 56%.3,24,25 Treatment consists of appropriate antibiotics

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given within 66 mins and tetanus vaccination as needed. thereafter is assessed by the skin’s ability to wrinkle.
Fracture fragments that are tenting the skin require Strict adherence to ice and elevation acutely can aid in
immediate reduction to limit damage to the local circula- reducing edema in preparation for definitive surgery. Open
tion and minimize the risk of conversion into an open injuries with soft tissue defects or tenuous closures benefit
injury. Evaluating the severity of soft tissue edema plays from negative pressure wound therapy and should be clo-
a critical role in determining timing of definitive fixation sely monitored with changes every 3–4 days.
of these complex injuries and often photographs should be
taken before splinting to compare with subsequent exams.
Preoperative Planning
Early definitive internal fixation in the setting of severe
Preoperative planning begins with a thorough evaluation
soft tissue swelling is associated with poorer outcomes and
of the patient’s co-morbidities, functional and social status.
increased complications, such as infections and wound
Factors such as sex, lower socioeconomic status, laborers,
dehiscence.11,26,27 The presence of fracture blisters can
and work-related injuries portend poorer outcomes. Next,
provide insight into the amount of soft tissue injury the
a thorough evaluation of the imaging obtained to define
patient has sustained. While their presence may not neces-
the diagnosis and develop a treatment approach. Traction
sarily require a delay in definitive fixation, their location
radiographs can provide a simple adjunct to injury films in
may limit the surgical approaches that can be utilized.
a patient too unstable for advanced imaging. General
Hemorrhagic blisters should be kept intact if possible as
restoration of the length, rotation, and axial alignment
their rupture confers communication to the subdermal
may help delineate the true fracture pattern, fragments,
tissue. Surgical fixation should be postponed until re-
and range of reduction. Computed tomography (CT) pro-
epithelization of the region is achieved.28,29
A staged protocol involving initial external fixation vides a more detailed evaluation of the articular segments
followed by delayed definitive treatment has shown favor- and most would agree is imperative for surgical planning.
able results.5,10,28,30,31 Metaphyseal spikes are often pre- Advantages of obtaining a CT scan after external fixation
sent, can tent the skin, and obstruct the blood supply or preliminary reduction and immobilization include an
leading to necrosis and eventual open injury and are accurate illustration of the fracture pattern, mobility of
usually difficult to reduce. To combat this issue, posterior the fragments, limit radiation exposure and cost but also
splint application or supplementation with metatarsal pins as this new information may change the approach com-
attached to the main ankle-spanning frame can help main- pared to a CT done prior to preliminary stabilization
tain a plantigrade foot and combat this issue.5,10,23,25,32,33 (Figure 1A–E).36,37 The most common fracture pattern
Proximal Schanz pins are placed well outside the zone of usually splits the articular surface into three variable yet
injury to prevent overlap of definitive fixation, if possible. predictable fragments: the medial fragment consisting of
Either a transcalcaneal or talar neck pin can be placed, the medial malleolus and adjacent weight-bearing seg-
taking care to avoid neurovascular structures.34 Use cau- ment, the anterolateral or Chaput fragment, and the poster-
tion with placement of the talar pin as communication with olateral or Volkman fragment usually with their
the ankle joint or definitive incision can lead to unwanted ligamentous attachments intact.38 The location of where
infection. Other proposed techniques involve early limited these fracture lines exit the cortex, position of articular
open reduction and internal fixation (ORIF) of metadia- segments, and if those fragments lie in continuity with the
physeal spikes and/or fibular fractures to provide further intact tibial shaft dictate the location of implant placement
protection of the soft tissue and enhance the stability of the and subsequently the surgical approach(es) used. In addi-
external fixator. This technique risks limiting future inci- tion to the boney injury, it is important to identify the soft
sions if placed in a position that violates a desired tissue components, usually with a “soft tissue window” on
approach. Furthermore, fixing segments in place prior to CT, to detect interposition of vital structures or evidence of
addressing the entire injury prevents their mobility during prior surgery/injury that may dictate changes in the opera-
reduction, and is generally discouraged.30,31,35 The main tive plan. There is a limited role for MRI in the acute
goal of these methods is to provide an environment for the setting of pilon fractures.
soft tissue to recover while restoring length, alignment, With these considerations in mind, concomitant inju-
and rotation of the limb. The peak inflammatory response ries, such as spine or abdominal injuries may prevent the
is usually reached by day 5 and resolution of edema patient from lying prone for posterior fixation and soft

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Figure 1 Fracture seen on plain radiographs (A, B), details of the injury further enhanced via CT (C–E). The CT axial cut (C) showing classic formation of the three main
fracture fragments, Tillaux-Chaput, medial malleolus, and Volkmann. Appreciation of the depression on CT can aid the surgeon in preparation of the metaphyseal defect
encountered after restoration of the articular surface. Final follow-up radiographs (F) demonstrating restoration of the articular surface and good anatomical alignment
following open reduction and internal fixation.
Abbreviation: CT, computed tomography.

tissue injury may dictate a staged approach to allow for additional incisions are required, adequate spacing
healing or flap coverage. between them is important to avoid skin necrosis and
Generally, an incision should overlay where the major- wound complications.5,18,39 Previous teachings were a
ity of implants will be placed for ease of instrument use minimum of a 7-cm skin bridge needed between incisions,
and limit superficial soft tissue insult. The deep interval is however low soft tissue complication rates in pilon frac-
more readily mobilized than the skin to accommodate tures were observed in patients that had an average of 5.9
implant placement and often multiple deep interval win- cm.39 Though likely of secondary importance to proper
dows may be required through a single skin incision. A reduction and implant placement, be mindful of the length
“work horse” surgical incision can be chosen depending of the incision as skin receives its blood supply from
on where one can visualize cortical alignment for a “read” overlapping angiosomes that may be insulted from the
during the reconstruction process or the area with the most injury or other incisions.
comminuted articular fragments allowing direct visualiza- The anteromedial approach is used for OTA 43B and C
tion for reduction to the more stable fragments.5 fractures and allows access for medial and anterior hard-
Traditionally, anteromedial and posterolateral approaches ware placement especially when the posterolateral
are used to maximize exposure and the ability to evaluate (Volkman) is the constant fragment.4,40,44,45 An incision
the majority of articular fragments.5,8,9,39–43 When is made 5 cm proximal to the ankle joint line, 1–2

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fingerbreadths lateral to the tibial crest to maintain full The incision for the posteromedial approach is made
thickness skin coverage over the near subcutaneous ante- along the posterior tibialis tendon (PTT) posterior to the
romedial tibia, and extended distally using a 60–80° curve medial malleolus and an interval is created between PTT
1 cm past the medial malleolus or along the tibialis ante- and flexor digitorum longus (FDL). Care is taken when
rior (TA) tendon toward the talonavicular joint.44,46,47 Care placing a retractor anterior to FDL and traction is limited in
is taken to avoid violating the TA tendon sheath due to the this region to avoid injury to the posterior tibial artery and
fact that injury to it would limit soft tissue graft options tibial nerve. Posteromedial approach can be utilized when
that can be used in the event of wound complications.48 addressing tendon or neurovascular bundle entrapment.42
Limitation of this approach is access to the anterolateral Due to the minimal skin bridge available between both
(Tillaux-Chaput) fragment that can be more readily posterior approaches, consideration should be made and the
addressed with Böhler’s anterolateral approach.41,49 area in need of direct manipulation should be chosen. If
For the anterolateral Böhler’s incision, with the foot in further exposure is needed, a small window for placement
neutral dorsiflexion, an incision is started 5 cm proximal to of a reduction aid can be used but with great caution.
the tibiotalar joint and extended distally in line with the
fourth metatarsal. Careful dissection is carried out in the Surgical Techniques
subcutaneous tissue to identify and protect the superficial Surgical indications for operative fixation of pilon frac-
peroneal nerve branches. Furthermore, the approach can tures include open injuries, 2 mm of articular displace-
be extended to visualize the talar dome, neck, lateral ment, talar subluxation, or malalignment greater than 5
degrees.8,9,36 Following AO principles, surgical fixation
talonavicular, subtalar, and calcaneocuboid joints without
should provide an anatomically reduced and stable con-
an increase in wound complications or difficulty in
struct, be conducted with gentle soft tissue handling, and
closure.41 Exposure to the anteromedial and anterolateral
allow for early rehabilitation and mobilization.1,2,9,51
fragments simultaneously can be obtained with the direct
General sequence in treating these fractures includes rees-
anterior approach with minimal soft tissue dissection via a
tablishing length and general axial alignment through fixa-
linear incision centered over the ankle avoiding the neu-
tion of the lateral column, restoration of the articular
rovascular bundle and being cognitive of its relation above
surface, filling of metaphyseal defects, and reattachment
and below the joint line.
to the diaphysis.8,9
The posterolateral approach is used to visualize the
Fibular reduction functions to prevent valgus deformity
posterior central and posterolateral distal tibia and fibula.
of the ankle and aides in reduction of the tibial plafond. By
The incision is made halfway between the posterior border
restoring the overall limb length, the ligamentotaxis effect
of the lateral malleolus and the lateral border of the
via the anterior inferior tibiofibular ligament and posterior
Achilles tendon with caution taken to identify and protect
inferior tibiofibular ligament allows indirect reduction of the
the sural nerve. The nerve usually crosses the lateral
anterolateral and posterolateral fragments, respectively.
border of the Achilles about 9.8 cm from its insertion or One-third tubular plates with penetration of six cortices on
about four fingerbreadths and travels retromaleolar in the either side combined with lag screws perpendicular to the
distal extent. A deep interval between peroneus longus and fracture site are sufficient for fixation. Over lengthening and
flexor hallucis longus is formed to visualize the posterior malreduction can lead to varus deformity of the distal tibia
tibia and fibula. The fibula fracture can be addressed and excessive loading of the lateral articular surface.47 The
through the same deep interval medial or lateral to the mortise view of the ankle is used to confirm the anatomical
peroneus muscles within the same incision. Though not reduction between the distal end of the fibula, lateral tibial
observed in our experience, caution should be utilized metaphysis, and talus.52 The fibula may not always have to
when using this approach, as there have been reports of be fixed. If the fibula cannot be restored to its anatomical
higher complication rates that include nonunion, wound position or does not aid in tibia reduction, it can be
issues, and suboptimal clinical outcomes when complete addressed after the pilon component or left to heal without
fixation is performed through one surgical approach.50 surgical intervention. Recent literature has shown that there
These issues may be mitigated with thorough skin prep, is no difference in final alignment when comparing fibular
strict hemostasis, longer incisions, and strict protection fractures with versus without fixation in nonrotational pilon
postoperatively due to its depended location. injuries.53 Some studies show patients with ORIF of the

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fibula had higher nonunion rates, occasionally required osteoconductive, osteoinductive, and osteogenic
plate removal and had an associated increased incidence properties.5,59 If not preliminarily reduced beforehand,
of superficial infections.53–58 the metaphyseal-diaphyseal dissociation is then addressed
Three main fracture fragments, medial malleolus, to realign the anatomical axis of the tibia. Columnar
Chaput, and Volkmann are commonly formed as a result restoration and stability should be obtained with the con-
of the fracture lines created in pilon injuries (Figure 1C).38 struct after anatomic articular reduction and fixation.
Again, the variability and personality of these fragments is Medial column stability is mandated in varus deformities,
dictated by the position of the foot and load applied, bone conversely lateral column for valgus deformities, posterior
quality, and presence of arthritis. In use of a 2-incision column for plantar flexion, and anterior column for dorsi-
approach, the posterolateral incision provides the surgeon flexion injuries.60 Proper contouring of the plates is impor-
with the ability to convert a complex pattern, OTA C-type, tant to avoid residual displacement during plate fixation
into one treated in a simpler manner, B-type. The poster- although this is irrelevant in the minimally invasive plate
olateral articular fragment is traditionally the more con- osteosynthesis (MIPO) technique.61,62
stant piece and can be the source of initial stability and The quality of the soft tissue in the region can limit
preliminary fixation especially if it remains in continuity the options of multiple plate fixation. To minimize
with the tibial shaft.45 In a severely comminuted scenario, further soft tissue injury caused by surgical dissection,
the posterolateral column should be restored with preli- minimally invasive techniques such as MIPO and intra-
minary reduction and fixation using a locking unicortical medullary nailing (IMN) have been popularized. Spatial
construct through a posterior incision in a staged fashion.
frame application is also a useful skill in a surgeon’s
This simplifies subsequent fixation from an anterior
armamentarium and can be utilized by those experienced
approach that is reconstructing the articular segments
in its principles and facile with the technique. Utilizing
from a posterior to anterior direction building to that stable
the MIPO technique, the extraosseous blood supply of
portion.35,43,44,46 Distraction through an AO distractor or
the medial distal tibia is less compromised when com-
external fixator can be utilized to obtain length, alignment,
pared to open plating.63 Challenges with this technique
and indirect reduction by means of ligamentotaxis.45 The
include plate tendency to drift posteriorly in the sagittal
use of a medial talar pin can induce a distraction, plantar
plane upon submuscular placement. Applying a K-wire
flexion, and valgus force. Conversely, a lateral calcaneal
in the posterior third of the tibia on the lateral view at
pin can induce a distraction, dorsiflexion, and varus force.
one half of the plate length can aid in aligning the plate
Preliminary reduction is obtained with the combination of
centrally.64 Though not always warranted, locking plates
elevators, osteotomes, and pointed reduction clamps then
have demonstrated reliable treatment for patients with
preliminarily fixed with Kirschner wires (K-wires) or bio-
osteoporosis or severe comminution and provide further
logic fixation pins. In the event of small irreconstructable
articular fragments, the impacted articular segment should stability against rotational forces.46 IMN has been
not be disrupted but manipulated as a whole by, using the shown to have a role when addressing both extra-articu-
talus as a template. One technique used is levering a wide lar (AO/OTA-43A1) and simple intra-articular (AO/
osteotome well above subchondral bone and incorporating OTA-43C1/C2) fracture patterns (Figure 2). After
a portion of spongy metaphyseal bone, to aid in dissipating addressing simple articular fractures with independent
focal point pressures, and dis-impacting the portion as one screw fixation, IMN placement restores the metaphy-
piece. By direct and indirect visualization under fluoro- seal-diaphyseal dissociation and restores the overall
scopy, the reduction is evaluated for restoration of the alignment of the distal tibia reliably without insult to
articular surface with standard ankle views as well as the surrounding soft tissue in the zone of injury.65 In the
oblique views to evaluate the anteromedial and lateral setting of severe non-reconstructable comminution,
corners for reduction. Keep in mind the inherent 3–5 osteopenia, and arthritis in a patient with poor healing
degree anterior tilt of the distal tibia articular surface potential, there is a role for acutely fusing the tibiotalar
when using fluoroscopy especially on the lateral view. joint. Denuding the cartilage of the talus and fusing the
Upon confirmation, K-wires are replaced with definitive joint using a compression plate or screw construct,
screw fixation, and the metaphyseal defect is then filled tibiotalar intramedullary device, or a combination with
with auto- or allograft substitutes ideally with addition of bone graft has proven to be successful.

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Figure 2 Fracture seen on plain radiographs demonstrating AO/OTA-43C2 (A). CT demonstrates a distal tibial spiral fracture with an associated posterior malleolus
fracture (B). The articular surface was restored with the use of independent screw fixation and buttress plating. IMN was then used to correct the coronal plane
malalignment. Syndesmotic screws were then used to address injury to the syndesmosis (C).
Abbreviations: CT, computed tomography; IMN, intramedullary nailing; AO/OTA, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association.

Summary measures but can be utilized as definitive fixation

Pilon fractures include a wide range of complexity. The when indicated. There is a role for acute fusion in
timing and type of definitive fixation is dictated by the severely comminuted, osteoporotic, or arthritic fractures
soft tissue injury and energy imparted to the fracture. in patients with poor healing potential.
One should have a low threshold for staged protocols
and delayed definitive fixation. Proper radiographs and Disclosure
advanced imaging should be obtained for an exacting The authors report no conflicts of interest in this work.
diagnosis and preoperative planning. Diligent manage-
ment of the soft tissue and anatomic restoration of the
articular surface, length, rotation and axial alignment References
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