Immediate priorities
Urgently reduce gross ankle deformity.
Apply a well padded splint.
Elevate the limb.
Treat open fracture according to open fracture principles.
Severe swelling usually precludes immediate definitive fixation.
Nonoperative treatment
Reserved for:
- Truly nondisplaced stable fractures
- Patients with prohibitive operative risk
- Selected very low demand patients
Use cast or brace immobilisation with strict surveillance.
Displaced articular pilon fractures generally have poor results with closed treatment alone.
Staged treatment
The standard strategy for most high energy injuries is:
Stage 1
- Restore gross length and alignment
- Apply ankle spanning external fixation
- Treat associated open wounds
- Perform urgent debridement when open
- Stabilise the fibula selectively where this assists reconstruction and does not compromise future approaches
Stage 2
Allow soft tissues to recover.
Definitive reconstruction is performed after:
- Marked swelling has subsided
- Fracture blisters have epithelialised or resolved appropriately
- Skin wrinkles have returned
This commonly takes approximately 7 to 14 days, but soft tissue condition rather than the calendar determines timing. Staged treatment is used for the majority of major high energy pilon fractures.
Definitive reconstruction
Classical principles are:
- Restore fibular length when required
- Reconstruct the tibial articular surface
- Fill clinically significant metaphyseal defects where structural support is required
- Restore tibial length and alignment
- Stabilise the metaphysis using plates with minimal additional soft tissue injury
Approach selection is determined by CT fragment anatomy.
Common approaches include:
- Anterolateral
- Anteromedial
- Posterolateral
- Posteromedial
Do not create narrow skin bridges between large incisions.
Articular reconstruction
Reduce major articular fragments anatomically.
Restore the relationship between:
- Medial malleolus
- Chaput fragment
- Posterior Volkmann fragment
- Central plafond
Articular impaction must be elevated before the metaphysis is fixed.
Subchondral defects can require cancellous graft or structural substitute.
Fibular fracture
Fibular fixation can:
- Restore length
- Assist reduction of the lateral plafond
- Improve ankle mortise alignment
But fixing the fibula during the initial stage is not obligatory in every case. It should fit the definitive reduction strategy and planned surgical approaches.
External fixation as definitive treatment
Circular or hybrid fixation may be useful when:
- Soft tissue injury makes extensive ORIF unsafe
- Open fracture contamination is severe
- Bone loss is substantial
- Patient factors make large internal implants undesirable
Limited articular fixation can be combined with a circular frame.
Primary ankle arthrodesis
Consider primary tibiotalar fusion in selected catastrophic injuries with:
- Nonreconstructible articular comminution
- Extensive cartilage destruction
- Major bone loss
- Severe contamination in a carefully selected reconstructive strategy
It is not routine for most pilon fractures.
Postoperative care
Begin ankle motion once wounds are stable and fixation permits.
Non weight bearing is commonly required for approximately 10 to 12 weeks, sometimes longer with severe comminution.
Advance loading only with convincing evidence of healing.
Complications are common:
- Wound necrosis
- Deep infection
- Osteomyelitis
- Nonunion
- Metaphyseal malunion
- Ankle stiffness
- Post traumatic osteoarthritis
- Chronic pain
- Secondary ankle arthrodesis
Even an anatomically reconstructed pilon fracture may develop arthritis because the initial axial impact can cause irreversible cartilage injury.
