Pilon fractures involve crushing injuries to the tibial plafond where the tibia meets the ankle. They are usually caused by high-energy impacts like falls or car accidents. Treatment depends on the fracture classification but commonly involves initial stabilization with external fixation followed by limited internal fixation once swelling subsides, in order to reduce complications. The goals are to restore anatomy, alignment and joint stability while avoiding further soft tissue damage.

1. What are they and how are they treated?
Dr Imran Jan

3. What is a Pilon Fracture?
 Pilon is a French word for pestle, an instrument used
for crushing or pounding. In many pilon fractures, the
bones of the ankle joint are crushed due to the high-
energy impact causing the injury. Pilon fractures may
be considered high-energy ankle fractures.
 Pilon fractures affect the bottom of the shinbone
(tibia) at the ankle joint. In most cases, both bones in
the lower leg, the tibia and fibula, are broken near the
ankle.

4. What is a Pilon Fracture?
 Pilon fractures are most often caused by
high-energy impacts, such as:
 Fall from height
 Motor vehicle/motorcycle collisions
 Skiing
 Risk Factors
Age. The average age of someone with a
pilon fracture is 35 to 40 years old. Pilon
fractures are rare in children and elderly
people. However, as our population ages,
seniors will account for a larger amount of
these fractures.
Male. Men are three times more likely
than women to have pilon fractures A pilon fracture often affects
both bones of the lower leg.

5. MECHANISM OF INJURY

6. How Does the Patient Present?
 Immediate and severe pain
 Swelling
 Bruising
 Tender to the touch
 Cannot put any weight on the injured foot
 Deformity ("out of place")—your ankle looks angled or
crooked

7. Pilon fractures
 HIGH VELOCITY INJURIES

8. CLASSIFICATION OF PILON #
 OTA CLASSIFICATION

9. The AO/OTA classification system provides a comprehensive
description of distal tibial fractures.
Type A fractures are extraarticular distal tibial
fractures, which are subdivided into groups A1,
A2, and A3, based on the amount of
metaphyseal comminution.
Type B fractures are partial articular fractures
in which a portion of the articular surface
remains in continuity with the shaft; these are
subdivided into groups B1, B2, and B3, based
on the amount of articular impaction and
comminution.
Type C fractures are complete metaphyseal
fractures with articular involvement; these are
subdivided into groups C1, C2, and C3, based
on the extent of metaphyseal and articular
comminution

10. Rüedi and Allgöwer
CLASSIFICATION
 .Type I fractures are nondisplaced cleavage
fractures that involve the joint surface
 Type II fractures have cleavage-type fracture
lines with displacement of the articular surface,
but minimal comminution;
 Type III fractures are associated with
metaphyseal and articular comminution.

11. RADIOLOGY
 ROUTINE X-RAYS-
AP, LATERAL, MORTICE VIEW
 CT SCAN- TO KNOW FRACTURE PATTERN AND
INTRAARTICULAR COMMUNITION

12. CLINICAL EXAMINATION
The extremity should be examined carefully for
1. signs of vascular injury
2. swelling
3. fracture blisters
4. soft-tissue crushing
5. closed degloving
6. compartment syndrome.

13. Blood-filled fracture blisters indicate
more extensive cutaneous damage
than blisters filled with clear fluid

14. GOALS OF TREATMENT
1. To obtain an anatomical articular reduction
2. Restore axial alignment
3. Maintain joint stability
4. Achieve fracture union
5. Regain functional and pain-free weight bearing
and motion
6. Avoiding infections and wound complications

15. TREATMENT CONSIDERATION
Depends upon
1. Fracture pattern
2. Soft-tissue injury
3. Patients age n comorbidities

16. MANAGEMENT
In undisplaced n debilitated pts with good skin
condition,non operative treatment
long leg cast for 6 weeks
Then brace and rom exercises
Disadvantages:
Loss of reduction
Inability to reduce intraarticular fractures
Inabilty to monitor soft tissue status

17. In case of bad skin condition-
While waiting…
 Limb Elevation
 Foot pumps
 Manage blisters
 Debride, Silvadene
 Optimize condition
 Nutrition
 smoking cessation

18. TREATMENT OPTIONS
 Nondisplaced fractures- A1, B1, and C1:
1. Cast immobilization
2. Calcaneal traction- Later cast immobilization
3. Ligamentotaxis with ex-fix
4. Limited fixation with 3.5-mm or 4-mm screws
5. percutaneous or limited open reduction
 All displaced fractures:
Staged surgery -More recently, staged
protocols have been advocated

19. Staged surgery
 First stage:
 External fixator spanning the ankle joint.
 With or without plating fibula
 Second stage
 Soft tissue swelling had subsided
 ORIF, reconstruction of the articular
surface
 Limited incision

20. EX-FIX MODALITIES
1. traditional half-pin fixators spanning the ankle
2. articulated half-pin fixators that allow ankle
motion
3. half-pin fixators that do not span the ankle
4. hybrid fixators that combine tensioned wires with
half-pins in the tibial diaphysis and do not span the
ankle joint.

21. A two-staged protocol
First stage: spanning external
fixator

22. External Fixation
Cross ankle (spanning)
Fixation into foot
•rigid
•articulated

23. External Fixation
Same side ( ankle sparing)
All fixation above ankle joint
•Ring & wire
•Ring/wire + pins (Hybrid)

24. second stage : limited incision and
internal fixation by absorbable
implants( screws and rods)

25. Limited open reduction

26.  Orif and plate fixation to achieve precisely
reduced articular surface
To min. complications
Use of precountoured low profile implants and mini fragment
screws are used
Antermedial incision over tibia avoided
Use of indirect techniques to minimize soft yissue stipping.
Use of percutaneous /MIPPO for plate fixation

28. Indirect Reduction
by
Ligamentotaxis

29. AP and Mortice images in temporary ext. fix.

30. Step 1Percutaneous K-wire joysticks

31. Step 2
Reduction of joint fragments, temporary K-wire fixation

32. Step 3
Percutaneous placement of pre-contoured plate

33. Step 4 Metaphyseal screw – buttress function

34. Step 5
Additional plate
screws

35. Lag screws as
needed

37. Complications:
1. Skin necrosis
2. Infection-
osteomylitis
3. Traumatic arthritis
4. Nonunion or
delayed union
5. Ankle joint
stiffness

38. Summary
 Select correct treatment for patient and
injury
 Delay definitive Internal fixation
 Early temporary external fixation
 Gently reduce and limit incisions
 Stable fixation
 Lag screws
 Buttress plates

39. THANK YOU!