Pilon Fracture (Tibial Plafond Fracture)

Summary

A pilon fracture is a major injury involving ankle joint.  The fracture involves the lower leg bone (tibia) and extends into the weight-bearing part of the ankle joint.  It usually occurs following a major load to the foot such as might occur from a fall from a height.  The bone of the lower part of the ankle (the talus) is driven into the top of the ankle joint causing the fracture.  It is a painful injury associated with a fair bit of swelling.  Treatment is often surgical if the fracture is displaced.  Surgery attempts to restore the shattered bone back to its original position. It often takes many months for the fracture to heal.  Some ankle arthritis is common even with optimally treated pilon fractures.

Clinical Presentation

A pilon fracture is a serious fracture involving the ankle joint.  It is a fracture of the lower part of main bone of the lower leg (the tibia).  The fracture extends into and involves the weight-bearing surface of the ankle joint itself.  This injury occurs from a loading injury to the foot such as would occur during a fall from a height.  Essentially, the foot gets jammed up into the lower part of the lower leg bone (tibia) and resulting in a significant fracture.  A pilon fracture is associated with marked pain and swelling.  Patients will not be able to load any weight on the foot.  The injury is often extremely uncomfortable.  It is common for patients to have other injuries if the cause was a high-energy injury such as fall or a motor vehicle accident.

Physical Examination

Physical examination will show significant swelling involving the ankle joint and the lower leg. There may be associated deformity if the ankle fracture is significantly out of position.  It is important to check the nerve and blood supply to the foot, as this can be compromised.  It is also important to check the other muscles, bones and joints to see whether there are any other injuries.  In addition, there is often limited muscle coverage over the ankle.  It is not uncommon for this injury to be open whereby a part of the fracture pokes through the skin.  If this occurs, it is necessary to get this treated surgically in an expedited manner in order to minimize the risk of infection.

Imaging Studies

A plain x-rays will usually allow the injury to be diagnosed.  It will identify the fractures that involve the lower leg bone and extend into the ankle.

A CT scan is usually required to view all of the various fracture lines and help the surgeon understand the nature of the fracture pattern which varies considerably from patients to patients.  The defining feature of a Pilon fracture is a fracture that extends into the weight-bearing portion of the ankle – the top part of the ankle joint surface itself.

Figure 1

Figure 1 -Pilon Fracture X-Ray

Treatment

Non-Operative Treatment

Occasionally, either because the fracture is non-displaced or because surgery is contraindicated, the patient can be treated without surgery.  Non-operative treatment requires a prolonged period (10 to 12 weeks) of non weight-bearing to allow the fracture to heal.  Patients are usually placed in a cast during that time.

Operative Treatment

Most Pilon fracture in otherwise healthy individuals are treated with surgical stabilization.  This is often performed once the swelling has settled.  This means that the surgery may be number of days or even weeks after the original injury.  During this time, the foot will be elevated and sometimes it will be placed in an external frame (external fixator) to help stabilize the soft tissues that are often significantly damaged after this type of injury.

The surgery itself can be quite complex.  It essentially involves repositioning the fractured bone fragments back into position.  It is particularly important that the bone that makes up the top part of the ankle joint (the tibial plafond) be restored to as close to a normal (anatomic) position as possible.  This procedure is performed through one or more incisions.  Once the fractures are provisionally fixed with wires they are definitively stabilized with a plate and screws -or series of plates and screws.

Following the surgery, the patient is kept non-weight bearing until the bone heals which often takes 10 to 12 weeks or more.

Figure 2

Figure 2 -Pilon Fracture Following Surgery

Potential Complications

This is a potentially very serious high-energy injury with a reasonably high complication rate.  The main surgical complications are:

Infection

Wound healing issues

Painful prominent hardware

This may also be a complication over time. In some instances the hardware will need to be removed after the fracture has healed.

Ankle Arthritis

Many patients who suffer a pilon fracture will develop some post-traumatic ankle arthritis.

Edited June 6th, 2013