Tibial Pilon Fracture

Tibial pilon fracture (also called tibial plafond fracture from French 'pilon' meaning pestle, due to the impact mechanism) is a complex intra-articular fracture of the distal tibial metaphysis involving the weight-bearing surface of the tibial plafond. Most are high-energy injuries from axial loading (talus driven into tibial plafond) such as fall from height, motor vehicle collision, or industrial accidents.

The injury is characterized by significant articular comminution, metaphyseal disruption with frequent fibular fracture (>75%), and severe soft tissue injury (high incidence of compartment syndrome, open fractures, and soft tissue compromise from blistering and swelling). Classifications include Ruedi-Allgower (Type I non-displaced articular split, II displaced articular fragments without comminution, III articular comminution with metaphyseal involvement) and AO/OTA 43-B (partial articular) or 43-C (complete articular).

Modern management favors a staged protocol: initial closed reduction with spanning external fixation across ankle to restore length and alignment, allowing soft tissue swelling to subside and blisters to heal (typically 7-21 days), followed by definitive open reduction and internal fixation (ORIF) with anatomic articular reconstruction and metaphyseal stabilization using anatomic plates (medial and/or anterolateral). Goals are anatomic articular reduction, restoration of length/alignment, stable fixation, soft tissue preservation. Complications: wound dehiscence, infection, malunion, nonunion, post-traumatic arthritis (40-60% require eventual fusion or replacement), chronic pain. Severe cases may require primary arthrodesis or future ankle arthrodesis/total ankle replacement.