Tibial pilon fracture

An axial load drives the talus into the tibial plafond and bursts the articular surface. The soft-tissue envelope is thin and often badly damaged, which dictates the timing of surgery.

Mechanism

Falls from height and road accidents (axial load); low-energy rotational variants in the elderly.

Clinical findings

• Severe swelling and fracture blisters; open wounds; check for calcaneal and spinal fractures (same mechanism).

Imaging

• AP, mortise and lateral of the ankle; AP and lateral of the whole tibia.
• CT, usually after spanning external fixation (ligamentotaxis makes the fragments easier to read).

• X-rays, then CT after spanning ex-fix to plan fixation (the three classic fragments: medial, anterolateral Chaput, posterolateral Volkmann).

Classification

43A

Extra-articular distal tibia.

43B

Partial articular.

43C

Complete articular (true pilon).

Rüedi–Allgöwer

I undisplaced, II displaced without comminution, III impacted and comminuted.

Types shown in 3D

43A

Extra-articular distal tibia (with fibula). Nail with distal locking or plate.

43B1

Partial articular, pure split (here the medial plafond).

43C

Complete articular: the joint surface breaks into the classic medial, anterolateral (Chaput) and posterolateral (Volkmann) fragments, and the talus is driven up between them.

Treatment

Staged protocol

Day 0: spanning external fixator (± fibular fixation) to restore length. When the swelling settles (often 7–21 days, wrinkle sign): anatomical reduction of the joint and plate fixation through approaches planned on CT.

Alternatives

Definitive ex-fix with limited internal fixation when the soft tissues are poor; primary arthrodesis in unreconstructable fractures.

Aftercare

Early ankle motion, non-weight-bearing 10–12 weeks.

Complications

• Wound necrosis and deep infection
• Post-traumatic arthritis (very common)
• Malunion, non-union