This document discusses tibial pilon fractures, which involve fractures of the distal tibial articular surface. Key points include: 1) The term "tibial pilon" was first used in 1911 to describe the distal tibia resembling a pestle. Pilon fractures account for 7-10% of tibial fractures and usually result from high-energy mechanisms. 2) Classification systems include the Rüedi-Allgöwer system (based on articular displacement/comminution) and the AO/OTA system (which further subdivides based on extra-articular involvement and comminution). 3) Treatment involves restoring tibial alignment, stabilizing the fracture to facilitate union,

1. Tibial P ond
laf
Fractures
(Pilon
Fr act ur es)
Muhammad Abdelghani

2. Historical Perspective

The term ‘tibial pilon’ was first
used by Destot in 1911,
likening the pilon to a pestle.

3. Definition

All fractures of the tibia
involving the distal articular
surface should be classified as
pilon fractures, except for
medial or lateral malleolar
fractures and trimalleolar
fractures where the posterior
malleolar fracture involves <
1
/3 of the articular surface.

4. Are isolated fractures of the posterior
malleolus considered pilon fractures?
 Yes

Isolated fractures of the
posterior malleolus
(Volkmann triangle) account
for 5% of tibial pilon
fractures.

5. Anatomy


Tibial pilon = the distal
end of the tibia including the
articular surface.
Proximal limit of tibial
pilon: 8-10 cm from the
ankle articular surface.

6. Epidemiology


Pilon fractures account for 7%-10% of all tibia
fractures.
Most pilon fractures are a result of high-energy
mechanisms.


Thus, concomitant injuries are common and should
be ruled out.
Most common in men 30-40 years old.

7. Mechanism of injury

Fracture pattern is dictated
by position of foot and
talus at time of impact:



Plantar flexion injury:
posterior lip fragment.
Neutral ankle: anterior and
posterior fragments.
Dorsiflexion injury: anterior
lip fragment.

8. Mechanism of Injury
Axial compression: fall from a height

The force is axially directed through the talus
into the tibial plafond, causing impaction of
the articular surface.



It may be associated with significant comminution.
If the fibula remains intact, the ankle is forced
into varus with impaction of the medial
plafond.
Plantar flexion or dorsiflexion of the ankle at
the time of injury results in primarily posterior
or anterior plafond injury, respectively.

9. Mechanism of Injury
Shear: skiing accident



Mechanism is primarily torsion
combined with a varus or valgus
stress.
It produces 2 or more large
fragments and minimal articular
comminution.
There is usually an associated
fibula fracture, which is usually
transverse or short oblique.

10. Mechanism of Injury
Combined compression and shear

These fracture patterns
demonstrate components of both
compression and shear.

The vector of these 2 forces
determines the fracture pattern.

11. Clinical Presentation

Patients typically present nonambulatory with
variable gross deformity of the involved distal
leg.

12. Clinical Evaluation

Full trauma evaluation and survey may be
necessary.



Most pilon fractures are associated with high-energy
trauma.
Assessment of neurovascular status
Evaluation of any associated injuries.

13. Clinical Evaluation

Swelling:
 Often massive and rapid
 Necessitates serial
neurovascular
examinations as well as
assessment of skin
integrity, necrosis, and
fracture blisters.
Soft tissue injury including
oedema, contusion and blisters
associated with pilon fractures

14. Clinical Evaluation

Meticulous assessment of soft tissue damage
 Significant damage occurs to the thin soft
tissue envelope surrounding the distal tibia as
the forces of impact are dissipated.

15. Plain Radiography

It is essential to have plain
films centered on the ankle as
well as films of the entire tibia.

16. Plain Radiography

Ankle films
 AP, lateral, and mortise views
 Delineate
articular incongruity and
fragmentation.

17. Plain Radiography

Tibial films
 Necessary
to fully evaluate the metaphyseal
and diaphyseal extent.
 Proximal injuries may easily be overlooked.

18. Plain Radiography

Traction X-Ray
 Traction
and ligamentotaxis often pull the
displaced fragments back into position,
allowing for a better definition and
understanding of the fracture pattern.

19. Radiographic Evaluation

Computed tomography (CT)
Used as an adjunct to plain films.
 Shows details often not readily available on most
plain films.
 Acts as guide to the articular injury for fracture
orientation, fragment location, and amount of
comminution or impaction.
 Aids in surgical decision making.


20. Radiographic Evaluation
The 3 classic articular
components of pilon
fracture (Axial CT):

1.
Anterolateral (Chaput
fragment)
2.
3.
Medial
Posterolateral (Volkmann
fragment)

These fragments vary in
their size and amount of
comminution

21. Radiographic Evaluation

Radiographs of the contralateral side may
be useful as a template for preoperative
planning.

22. Radiographic Evaluation

The 3 important anatomical
zones to be considered in the
decision-making and
prognosis:
1.
2.
3.
Articular surface
Metaphysis
Fibula

23. Associated Inuries

Because of their high-energy nature, these
fractures can be expected to have specific
associated injuries, e.g.:
 Calcaneus fractures
 Tibial plateau fractures
 Pelvis fractures
 Vertebral fractures

24. Classification
Rüedi & Allgöwer
Commonly used today
 Based on the severity of comminution and
the displacement of the articular surface.


25. Classification
Rüedi & Allgöwer



Type I: Nondisplaced
cleavage fracture of the
ankle joint
Type II: Displaced
fracture with minimal
impaction or
comminution
Type III: Displaced
fracture with significant
articular comminution &
metaphyseal impaction

26. Classification
Rüedi & Allgöwer


Ovadia and Beals added types IV and V to include
fractures that extend into the metaphyseal and
diaphyseal regions with more severe comminution,
which is characteristic of many high-energy injuries
Prognosis correlates with increasing grade.

27. Classification
Mast

Combination of the Lauge-Hansen classification of
ankle fractures and the Ruedi-Allgöwer classification.



Type A: Malleolar fractures with significant posterior lip
involvement (Lauge-Hansen SER IV injury)
Type B: Spiral fractures of the distal tibia with extension into
the articular surface
Type C: “Central impaction injuries” as a result of talar
impaction, either with or without fibula fracture;

subtypes 1, 2, and 3 correspond to the Ruedi-Allgöwer classification

28. Classification
AO/OTA



An even more comprehensive
classification.
Includes subdivisions based on
amount of comminution.
Very useful for research as it
permits a more exact
description of the injury,
allowing better comparisons
between studies.

29. Classification
AO/OTA

Three main subgroups:





Extra-articular (43-A)
Partial articular (43-B)
Complete articular (43-C)
These are further divided into subgroups depending
on the comminution.
Most type B fractures have traumatic torsion
mechanisms, while the C-type usually have high
energy compression mechanisms.

30. Treatment

Treatment challenges:
Difficulties in anatomical reduction of the articular
surface
 Instability may occur due to ligamentous and soft
tissue injury
 Numerous soft-tissue complications may be
encountered during treatment


open surgery is associated with poor wound
healing, restoration of the anatomy is difficult
and delayed union and infection are common.

31. Treatment

Factors dictating treatment strategy:
Patient age & functional status
 Severity of injury to bone, cartilage, and soft tissue
envelope
 Degree of comminution and osteoporosis
 Capabilities of the surgeon


32. Treatment

Possible treatment methods:
 Conservative
treatment with cast
 Open reduction and internal fixation (as
described by Riiedi and Allgower)
 Combination of different types of external
fixators with or without internal fixation

33. Treatment

Strategies for an optimal outcome:
 Anatomical
reconstruction of the joint
 Restoration of tibial alignment
 Stabilization of the fracture to facilitate union

34. Treatment



Understanding of the anatomy of the fracture
should allow the development of improved
operative techniques and outcomes.
Proper length and rotation are critical, as are
preserving and maximizing ankle and subtalar
motion.
Even when these goals are met, there is no
guarantee that patients will have an acceptable
result.

35. Treatment
Non-operative


Long leg cast for 6 weeks followed by fracture
brace and ROM exercises or early ROM
exercises.
Indications:
Nondisplaced fracture pattern
 Severely debilitated patient


Manipulation of displaced fractures is unlikely to
result in reduction of intraarticular fragments.

36. Treatment
Non-operative

Disadvantages:
 Loss of reduction:
common
 Inability to monitor soft tissue status and
swelling

37. Treatment
Operative


Displaced pilon fractures are usually treated
surgically.
Helfet (1994) was the first to propose a twostage protocol for this type of fracture:


First stage: Temporary external fixation, to restore
length, alignment and rotation of the limb + ORIF of a
fibular fracture, if present, if the soft tissue allows.
Second stage: Definitive surgery, when the soft tissues
have recovered sufficiently to limit the likelihood of
complications.

38. Decision making flowchart

39. Treatment
Operative
TIMING OF SURGERY



Proper timing of treatment is required to
minimize soft-tissue complications.
Interventions must respect the underlying tissue
and the amount of surgery that the soft-tissue
envelope can tolerate.
Staged procedures are therefore often required
to reduce complications and maximize
functional results.

40. Treatment
Operative

TIMING OF SURGERY
Staged protocols have been shown to be
effective in preventing complications related to
soft tissue.
Immediate or early intervention (within 12-18 h of
injury) is usually limited to stabilization of the fibula
with a plate, using transarticular external fixation to
keep the extremity out to length and to obtain a
preliminary reduction by ligamentotaxis.
 Definitive reconstruction can be performed at a later
date.


41. Treatment
Operative
SKELETAL TRACTION



If more than a few hours have elapsed between the
injury and the evaluation, the soft-tissue swelling will be
too great to allow for immediate ORIF.
In this situation, skeletal traction (using a calcaneal pin
or an external fixator) should be used to prevent
skeletal shortening while awaiting for soft-tissue
recovery (which may take days or weeks).
Indirect reduction with traction helps to realign the
fracture surfaces, which makes subsequent internal
fixation easier to accomplish.

42. Treatment
Operative
SKELETAL TRACTION



Placement of the external fixator creates a more
optimal environment for soft-tissue healing.
It is necessary to wait for the reepithelialization
of each blister locally and assess the status of the
skin until the wrinkle sign of the skin is positive.
Associated fibula fractures may undergo ORIF at
the time of fixator application.

43. Treatment
Operative
DEFINITIVE RECONSTRUCTION



Definitive reconstruction through open approaches
should be delayed until soft-tissue swelling has
decreased, as the tissues are tenuous and cannot
withstand surgical trauma.
Surgery should be delayed for at least 10 days to allow
wrinkles to return, blisters to re-epithelialize, and
wounds to heal.
In some cases delaying the procedure for up to 4 weeks
may be required to allow soft-tissue swelling to subside.

44. Treatment
Operative
DECISION MAKING





What kind of incision should be made, medial
or lateral?
Which implant will maintain the reduction the
best?
Should an external fixator be used?
Should it be placed temporarily or used for
definitive treatment?
Should treatment be staged or done all at once?

45. Treatment
Operative
GOALS
Maintenance of fibula length and stability.
 Restoration of tibial articular surface.
 Bone grafting of metaphyseal defects.
 Buttressing of the distal tibia.


46. The 4 traditional principles of reconstruction

47. Treatment
Operative



SURGICAL TACTIC
Articular fracture reduction can be achieved
percutaneously or through small limited
approaches assisted by a variety of reduction
forceps, with fluoroscopy to judge fracture
reduction.
The metaphyseal fracture can be stabilized either
with plates or with a non-spanning or spanning
external fixator.
Bone grafting of metaphyseal defects

48. Limited Open Reduction

49. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 Like in all articular fractures, ORIF is the
most reliable way to obtain an anatomic
reduction of the articular surface.
 However, this option should be carefully
weighted against:


Soft-tissue condition (vascularity may be
affected by surgical approach if too early)
comminution and number of fragments.

50. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 After soft-tissue recovery, a limited open reduction and
stabilization of the articular component is done with
screws alone or with screws and a small buttress plate.
 Location of incisions and steps of reduction are based
on the preoperative plan.
 Soft-tissue dissection should be minimized and
fragments should remain attached to the periosteum
and the joint capsule.

51. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 The
first step is the fixation of the
fibula, to regain the correct length of
the tibia and to facilitate the threedimensional orientation and reduction
of the fracture.

52. Treatment
Operative
SURGICAL TACTIC
Internal fixation:




Several surgical approaches to the tibia have been described
for the treatment of these fractures.
Whatever the surgical route chosen, the surgical approach
should be centred on the larger bone fragment and care
taken not to traumatize the skin with aggressive surgical
technique.
An arthrotomy is essential for the accurate reduction of
articular fragments.
Keep a maximum of 2 mm of incongruity of the articular
surface.

53. The distance between the
two incisions should not
be less than 6-7 cm

54. Anteromedial approach

55. Anterolateral approach

56. Posterolateral approach, allowing access to the
fibula

57. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 The articular surface generally is reassembled from lateral to
medial and from posterior to anterior.
 The anterolateral portion of the tubercle of Chaput usually is still
attached to the anterior syndesmotic ligaments and is brought
down into position at the time of fibular reduction.
 The anterolateral corner of this reduced fragment can be used as
a guide for the restoration of tibial length.
 Any posterolateral or posterior fragments then are reduced to the
anterolateral fragment.
 The remaining fragments, including any central depressed
fragments, then are realigned.

58. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 When necessary, the split medial malleolar
fragment can be retracted posteriorly to allow
for better visualization of the articular reduction.
 Temporary fixation is obtained with K-wires,
and the reduction is confirmed radiographically.

59. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
 Bone-grafting of any structurally deficient areas
in the cortical or cancellous bone of the
metaphysis then should be done.

60. Treatment
Operative
SURGICAL TACTIC
Internal fixation:
When plate fixation is planned, an anterior
or anteromedial buttress plate is used,
depending on the fracture configuration.
 Large spoon and T-plates no longer are
recommended (too bulky and can
compromise the overlying soft tissues).


61. Spoon plate as
an anterior
buttress plate.
This plate
should never be
used; rather, a
lower profile
implant as one
may use in the
distal radius
should be used

62. Treatment
Operative
SURGICAL TACTIC
Internal fixation:



A 3.5-mm cloverleaf plate has a much smaller profile
than the large-fragment-system plates but still has
adequate strength to maintain reduction and can be bent
and contoured relatively easily for positioning on the
tibia.
Cannulated screws can be placed independent of the
plate, either through the wound or percutaneously, to
secure isolated fragments.
The importance of meticulous care of the soft tissues,
including a tension-free closure, cannot be
overemphasized.

66. Treatment
Operative
SURGICAL TACTIC
Techniques to minimize plating
complications:
Surgical delay until definitive surgical treatment using
initial spanning external fixation for high energy
injuries
 Use small, low-profile implants
 Avoid incisions over the anteromedial tibia
 Use indirect reduction techniques to minimize soft
tissue stripping
 Use percutaneous techniques for plate insertion


67. MIPO
MIPO

68. Treatment
Operative
SURGICAL TACTIC
External Fixation as Definitive
Treatment:
 This has been of interest in recent
years, particularly for its benefits
with respect to minimal
interference with the soft tissue.
 External fixators can be either
unilateral or circular, they may span
or not the ankle joint and may
permit or not its motion.
Portable traction

69. Treatment
Operative
SURGICAL TACTIC
External Fixation as Definitive
Treatment:
 The principle of treatment with an
external fixator is through
ligamentotaxis.
 While most fixators are constructed to
provide a tibiotalar-calcaneal bridge,
circular fixators allow a tibial-only
assembly.
 This can allow early ankle mobilization
and, depending on the size and
orientation of the wires, a juxtaepiphyseal assembly and partial control
over the comminution of the fragments,
which may be assembled under
arthroscopic control.

70. Tibial
Safe
Zones

72. Treatment
Operative
SURGICAL TACTIC
External Fixation as Definitive
Treatment:



The assembly of the external fixator
should not jeopardize the attainment of
an eventual coverage flap.
The pins of the fixator should not be
placed along the course of a possible
incision site for future surgical treatment.
The assembly of the external fixator
should, as with internal fixation, be
preceded by the fibular synthesis, where
necessary and if the soft tissue allows, in
order to restore the correct length.
Circular frame (LiMA) external
fixation of a pilon fracture

74. Treatment
Operative
SURGICAL TACTIC
Articulating vs non-articualting spanning external fixation:

Nonarticulating (rigid) external fixation:



most commonly used.
Theoretically allows no ankle motion.
Articulating external fixation:


Allows motion in the sagittal plane, thus preventing ankle varus
and shortening.
Application is limited, but theoretically it results in improved
chondral lubrication and nutrition owing to ankle motion, and it
may be used when soft tissue integrity is the primary indication
for external fixation.

75. Treatment
Operative
SURGICAL TACTIC
Hybrid external fixation:



A type of nonspanning external fixator.
Fracture reduction is enhanced using
thin wires ± olives to restore articular
surface and maintain bony stability.
Especially useful when internal fixation
of any kind is contraindicated.

76. Treatment
Operative
SURGICAL TACTIC
Hybrid external fixation:



With severe soft-tissue injuries or open
fractures, a hybrid ring fixator for the tibia may
be used in combination with standard plating of
the fibula.
As definitive treatment, this technique is only
suitable for simple articular fractures, which can
be reduced anatomically by indirect reduction
techniques and fixed by percutaneous lag
screws.
In complex fractures an anatomical and stable
reconstruction of the articular bloc usually
requires ORIF.

77. Treatment
Operative
SURGICAL TACTIC

If an external fixator is used, weight-bearing
should be delayed until there is radiographic
evidence of bone healing.

78. Treatment
Operative
SURGICAL TACTIC
Arthrodesis:
 Seldom performed acutely.
 Reserved only for severe articular comminution
which is not otherwise reconstructable
 Best done after fracture comminution has
consolidated and soft tissues have recovered.
 Generally performed as a salvage procedure after
other treatments have failed and posttraumatic
arthritis has ensued.

79. Treatment
Operative




Open Pilon Fractures
Open pilon fractures present an additional
challenge.
Like all open fractures, they require emergency
debridement, irrigation, and stabilization.
The typical wound associated with an open pilon
fracture is a transverse distal anteromedial
laceration.
The proximal skin flap is contused, and use of the
usual anteromedial incision may compromise its
blood supply.

80. Treatment
Operative

Open Pilon Fractures
Steps in treating open pilon fractures:
Apply an external fixator
 Obtain indirect reduction
 Stabilize the fibula
 Perform the reconstruction of the articular surface
through the open wound with use of cannulated
screws for stabilization.


This technique has been found to be less traumatic
to the already injured soft tissues than the
traditional extensile exposure.

81. Treatment
Operative
Open Pilon Fractures

Cancellous bone-grafting and even internal
fixation can, if necessary, be delayed until 4-6
weeks later, when the soft tissues have stabilized
and the risk of soft-tissue slough and infection is
reduced.

82. Post-operative Management



Initial splinting in neutral dorsiflexion with careful
monitoring of soft tissues.
Early ankle and foot motion when wounds and
fixation allow.
Non-weight bearing for 12-16 weeks, then
progression to full weight bearing once there is
radiographic evidence of healing.

83. Main pitfalls and the resulting complications in
operated pilon fractures

84. Complications


Pilon fractures, especially those caused by highenergy trauma, have been associated with a high
rate of complications.
Even when accurate reduction is obtained,
predictably excellent outcomes are not always
achieved, and less than anatomic reduction can
lead to satisfactory outcomes.

85. Complications

Early postoperative
problems:
Skin necrosis
 Superficial and deep
infection
 Loss of fixation.


Complications with
fracture healing:



Delayed union or non-union
of the metaphyseal-diaphyseal
junction
Varus or valgus malunion of
the distal part of the tibia
Non-anatomical reduction or
postoperative loss of
reduction of articular surface

86. Complications

Soft tissue slough, necrosis, and hematoma: result
from initial trauma plus improper handling of soft tissues.




Avoid excessive stripping
Avoid skin closure under tension
Secondary closure, skin grafts, or muscle flaps may be required
for adequate closure.
Prevalence of postoperative skin and wound problems decreased
substantially with use of the technique of indirect reduction with
external fixation and reconstruction of the articular surface with
small plates or screws, or both.

87. Complications

Nonunion: Results from significant comminution
and bone loss, as well as hypovascularity and
infection.

Incidence: 5%, regardless of treatment method.

88. Complications

Malunion: Common with non-anatomic reduction,
inadequate buttressing followed by collapse, or
premature weight bearing.
Incidence: up to 25% with use of external fixation.
 Stabilization of the anterolateral fragment and bonegrafting of the lateral border of the distal part of the
tibia promote union and reduce the prevalence of both
valgus malunion and non-union of this fracture.


89. Complications

Infection: Associated with open injuries and soft
tissue devitalization.
Highest incidence with early surgery under unfavorable
soft tissue conditions.
 Late infectious complications may manifest as
osteomyelitis, malunion, or nonunion.


90. Complications

Posttraumatic arthrosis:
Results from damage of articular cartilage at the time of
injury
 Also associated with fractures in which a congruous
articular surface was not restored or maintained.
 Primary ankle arthrodesis is rarely indicated because the
long-term outcome is not easy to predict.
 Although some patients may need an ankle arthrodesis
because of symptomatic osteoarthrosis, others do fairly
well despite radiographic signs of post-traumatic
osteoarthrosis.


91. Complications

Tibial shortening: Caused by fracture comminution,
metaphyseal impaction, or initial failure to restore
length by fibula fixation.

92. Complications

Decreased ankle ROM: Patients usually average
<10°of dorsiflexion and <30°of plantar flexion.

93. Refernces


Sirkin MS: Plating of Tibial Pilon Fractures. Am
J Orthop. 2007;36(12 suppl):13-17.
Topliss CJ, Jackson M, Atkins RM: Anatomy
of pilon fractures of the distal tibia. J Bone Joint
Surg [Br] 2005;87-B:692-7.