Pilon Fracture (Tibia Plafond Fracture)

Edited by Hossein Pakzad, MD

Summary

A Pilon fracture is a major injury involving the ankle joint. The fracture involves the lower leg larger bone or tibia and extends into the weight bearing surface of the ankle joint. It usually occurs following a major load to the foot such as a fall from a height or motor vehicle accident (MVA).  The bone of the lower part of the ankle joint or the talus is driven into the top of the ankle joint causing the fracture.  It is a painful injury associated with a fair amount 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 and joint stiffness is common even with optimally treated Pilon fractures.

Clinical Presentation

Patients with Pilon fracture usually had suffered an excessive load or force to the ankle joint such as a fall from a height or MVA. It is common for patients to have other injuries. They normally cannot walk on the affected limb due to pain and distorted anatomy. A Pilon fracture is associated with marked pain and swelling and is often extremely uncomfortable.

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 the normal position.  It is important to check the nerve and the 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 associated injuries.  There is limited muscle and soft tissue coverage over the ankle joint and 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 elaborate the fracture pattern and help the surgeon understand the nature of the fracture 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 joint.

Figure 1

Figure 1 -Pilon Fracture X-Ray

Treatment

Non-Operative Treatment

Occasionally, either because the fracture is nondisplaced 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 splint and cast during that time.

Operative Treatment

Most Pilon fractures in otherwise healthy individuals are treated with surgical stabilization.  This is often performed once the swelling has settled.  This means that the surgery will be prefomred  a number of days or even weeks after the original injury when soft tissue is ready.  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 the right 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. Sometimes the fibula or the smaller bone located on the side of the ankle joint is also fractured and needed to be fixed.

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