The tibia (shin bone) and the fibula are the bones of the lower leg. Pilon fractures are injuries that occur at the lower end of the tibia and involve the weightbearing surface of the ankle joint. The fibula may or may not be broken. These injuries were first described more than 100 years ago and remain one of the most challenging problems for orthopaedic surgeons to treat.
The word "pilon" (pronounced "pee-lahn") comes from the French and means "pestle." A pestle is a tool used for crushing or pounding things. In a pilon fracture, the tibia bone may be crushed into several pieces due to the typically high-energy impact of the injury. These
injuries can also occur with lower energy in individuals with weak bones (i.e., osteoporosis).
Pilon fractures are very painful and debilitating injuries. Symptoms include pain and inability to bear weight on the leg. They often result in an obvious deformity of the ankle joint. Swelling occurs quickly and can be followed by bruising.
Pilon fractures occur when the talus bone under the ankle joint is driven into the leg with such force that the leg bone(s) break at the ankle joint. Common causes of pilon fractures are falls from heights and car accidents.
Your foot and ankle orthopaedic surgeon will take your medical history and perform a physical examination of your leg and ankle. The results of this exam will help the surgeon to determine how best to treat the pilon fracture. Your surgeon will be watchful for other injuries that may be present.
In addition, your surgeon will take X-rays of your leg and ankle to see how badly the tibia and fibula are broken. The bones may be broken in multiple places. The surgeon also may get a CT scan of your ankle to view all the broken areas of the tibia and
fibula in order to assist in caring for your particular injury.
Some pilon fractures do not need surgical treatment. These are typically lower-energy injuries to the tibia and fibula at the ankle joint. The bones are broken but not shifted too far out of place. These injuries tend to be less severe and can be treated with a leg cast.
Most pilon fractures have multiple breaks. There often are large separations between fractured fragments. These fractured bones often benefit from surgery.
The goals of pilon fracture surgery are to bring the bone pieces at the joint surface back together, to make the leg straight, and to allow healing of the tibia and fibula at the ankle joint. Once the fractures are healed, the goals are to restore your ankle's movement and strength.
X-ray images of a pilon fracture before surgery (left) and after surgery (right). The fracture is fixed with a plate and screws.
Specific Technique
Often, pilon fracture surgery is done in two steps to protect the skin and soft tissue. Foot and ankle orthopaedic surgeons do not routinely perform incisions through areas of damaged skin because doing so may result in wound healing problems. Surgeons often must wait until a patient's soft tissue improves before incisions can be made. A notable exception would be an open fracture where the bone has penetrated through the skin during the initial bone break.
Stage One
In many cases the first stage in treating pilon fractures is by surgically applying an external fixator to the patient's leg. This fixator is a frame applied outside of the leg that holds the leg and ankle in proper position.
This allows both the patient and surgeon to regularly inspect the soft tissue of the leg and ankle without frequent splint changes. The fibula fracture may be treated with a plate and screws at the same time the external fixator is placed. This part of the procedure is known as "open reduction
and internal fixation" (ORIF) of the fibula.
After surgery, you will need to keep your leg elevated above the heart to reduce swelling. It may take several weeks after the first surgery before the soft tissues improve and the leg is ready for the second stage of surgical treatment. This delay can be frustrating, but it may be necessary to minimize the risk of a wound healing problem. The wait does not affect overall results. In some cases the external fixator is used as the final treatment and is kept in place for many weeks to months.
Stage Two
The second stage of surgical treatment is to remove the external fixator and fix the tibia fracture using plates and screws. The fibula may also receive an ORIF if it was not fixed in the first stage.
When an external fixator is applied surgically to the leg, steel pins are placed in the tibia far above the fracture and also in the heel (calcaneus) and foot (metatarsals) bones far below the fracture. The pins are placed through small incisions that minimize damage to the soft tissues. They attach to metal bars outside the skin. The external fixator helps to hold the leg and ankle in proper position while your soft tissues heal and swelling goes down.
This next step is an ORIF of the tibia bone. This step may be delayed several days or even weeks after the initial surgery. The incisions typically are at the front or the inner side of the ankle. Other incisions may be made depending on the injury. The broken fragments are put back together and held in place with metal plates and screws. Special care is taken to restore the shape and stability of the ankle joint. The fibula may be fixed with an ORIF if that was not done previously. The incisions are then sewn together. The external fixator is typically removed and the leg is placed in a splint. This involves slabs of plaster or fiberglass that are applied to the rear and sides of the leg, ankle and foot. Special care is taken to cushion the leg with appropriate padding.
It often takes 3-6 months for the breaks in the tibia and fibula bones to heal. Until the bones fully heal, the patient's leg and ankle cannot be stressed or worked too hard. Advancing activity too soon before the tibia and fibula bones are healed can jeopardize the repair and ultimately bone healing.
The surgeon will schedule regular follow-up visits to monitor healing of the fracture and advance the patient's activity as appropriate. Many surgeons have a specific schedule for patients to see them in the office for post-surgical follow-up until the pilon fracture is fully healed.
The patient's first post-surgical visit is usually about two weeks after surgery. The splint is removed and the patient's leg is examined. The sutures/staples are removed if the incisions are healing well. If there is more severe leg swelling, the surgeon may wait longer before removing the sutures/staples. X-rays of the leg and ankle are performed to confirm that the tibia and fibula fractures are still in place. The leg in then placed in either a cast or a removable boot.
At each follow-up visit with the surgeon, the surgeon or their assistant will check on the patient's soft tissue, bones, and ankle joint. The soft tissue of the leg is checked for swelling and wound problems, while the bones are checked on X-rays to make sure healing is progressing. The ankle joint is checked for movement, strength, and stability.
Patients are restricted from full weight bearing on their operated leg until there is complete healing of the tibia and fibula bones. Patients are not allowed to bear weight on their leg in their post-surgical splint. Patients are not allowed to bear any weight on their operated leg until there is evidence of bone healing. This period of non-weight bearing is with the leg in either a cast or boot. It usually takes 6-12 weeks to see initial bone healing on X-rays.
As long as the patient’s tibia and fibula are healing with each subsequent visit, weight bearing activity gradually can be increased in the protective boot. Patients ultimately can remove the boot and gradually resume activities in normal shoes.
The time to achieve full bone healing of a pilon fracture typically occurs 3-6 months after surgery, but it often takes patients 12 months or more to fully recover from the injury. Pilon fractures are serious injuries. Most patients do not return to the same function that they had before getting hurt. It is common for patients to have residual aches, swelling, stiffness, and weakness even after the tibia and fibula bones are healed. Most patients will need physical therapy to help in their recovery.
Early complications are problems that can occur within the first few weeks after surgery. Many of these are wound-related, whether these are healing problems or infection. Some of these can improve with wound care and oral antibiotics. Deeper wound problems or infections can occur and are more severe. These problems often need further surgery or stronger antibiotics to eliminate the infection.
Other potential complications can occur within several months after surgery. Many of these involve difficulties with bone healing at the fractured areas. The risk of difficult bone healing increases greatly if the patient uses any form of nicotine (cigarettes,
cigars, chew, vaping, gum, patch).
Some patients experience "delayed unions" in which the bones ultimately heal but take longer than 6 months to do so. Many delayed unions can improve by immobilizing the leg and limiting full activities for the longer amount of time it needs to heal. Some surgeons may recommend that the patient use a "bone stimulator." This is a removable device that is worn on the patient's leg that uses ultrasound or electrical impulses to help stimulate bone healing.
Another potential problem is a nonunion. This is when the bones do not fully heal. Some nonunions develop when the blood supply to the bones has been damaged from the injury. Other nonunions occur if there is too much movement between fractured pieces of bone. Some of these can be treated in the same way as delayed unions. Other nonunions may need surgery. The surgery to treat the nonunion depends on an individual’s situation. It may involve procedures like adding healthy bone from other parts of the body or chemicals to help stimulate bone healing.
Long-term complications can occur many years after the patient’s pilon fracture is healed. The most common is ankle arthritis. Restoring tibia and fibula bone and ankle joint alignment lessens the chance of patients developing ankle arthritis. However, the cartilage at the tibia that helps to cushion the ankle joint can be irreversibly damaged during the initial injury. Arthritis can result in pain, swelling, stiffness, and weakness at the leg and ankle.
It is true that your ankle is at risk for developing arthritis after sustaining a pilon fracture, but the chances of developing ankle arthritis generally are lower with surgery compared to non-surgical treatment. Surgery offers the advantage of putting the broken pieces of the tibia and fibula back together. The chances of developing arthritis are reduced if the shape of the joint is restored, compared to the joint healing in an abnormal shape without surgery.
There are very few reasons to remove any internal plates or screws from the tibia and fibula bones. One reason would be if they are painful after the fracture is healed. This involves surgery on your leg to get them out. Another reason for implant removal would be if it became infected. This can happen while your fracture is healing or after it has already healed. The treatment for infection can be very complex and depends on your specific situation.
To help your tibia and fibula bones heal best after your pilon fracture surgery, follow your surgeon's post-surgical instructions. Advancing activity too soon after surgery can jeopardize the implants fixing the bones and ultimately bone healing. The surgeon must restrict the patient in certain ways after surgery for the bones to heal properly.
There are other things that you can do to improve the chances of the ankle joint and bones healing properly. A diet that is too low in protein can result in decreased bone and wound healing. Increasing your calcium and vitamin D intake may help with bone healing. Taking the recommended daily allowance of both (1,000 to 1,200 mg of calcium and 600 to 800 IU of vitamin D) may help your body to heal. Up to 2,000 mg of calcium per day may help broken bones to heal.
Drinking alcoholic beverages should be limited to no more than two drinks per day. All forms of nicotine (cigarettes, cigars, chew, vaping, gum, patch) should be stopped completely prior to surgery as they can be harmful to bone and wound healing.
Original article by Jamal Ahmad, MD
Contributors/Reviewers: Glenn Shi, MD; Jeffrey Feinblatt, MD
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