![]() ![]() High-energy injuries may present with obvious deformities and open wounds however, lower energy torsional injuries may be more difficult to detect. With pilon fractures, careful inspection of the patient’s lower extremities can further provide clues as to the extent of soft tissue insult. Once the patient is stabilized, a thorough history and secondary survey are necessary to identify the injury mechanism and other potential injuries. Initial evaluation and resuscitation should follow the Advanced Trauma Life Support (ATLS) guidelines and begin with the ABCs of a primary survey. Patients who sustain high-energy pilon fractures may also present with multi-system trauma and other life-threatening injuries. The extent of soft tissue injury, however, does not always correlate to the degree of fracture comminution. High-energy injuries are typically also associated with severe soft tissue destruction, which can present a major risk factor for wound complications and deep infections. Open fractures comprise approximately 20% of pilon fractures. Fragments that maintain their normal alignment or fractures without this typical Y-shaped pattern may be indicative of ligament rupture. The anterior or Chaput fragment is attached to the anterior inferior tibiofibular ligament (AITFL) the posterior or Volkmann fragment is attached to the posterior inferior tibiofibular ligament (PITFL) the medial malleolar fragment is attached to the deltoid ligament. Ligamentous attachments to the distal tibia contribute to this predictable fracture pattern. Several studies have also demonstrated the morphology of three major fragments (anterior, posterior, and medial) in a Y-shaped pattern on axial imaging. Low-energy torsional injuries lead to less articular comminution and larger fracture fragments that remain in continuity with subchondral bone. Associated fibular fractures are commonly present. The impact from an axial compression mechanism drives the articular surface proximally into the metaphysis, with associated metaphyseal comminution. The mechanism and degree of injury involved dictate the fracture pattern and the treatment approach to pilon fractures. In addition to classifying the fracture type, consideration must be given to the extent of soft tissue damage using the Gustilo-Anderson classification for open fractures or the Tscherne classification for closed fractures. ![]() In the AO/OTA classification for long bone fractures, pilon fractures are classified as extra-articular (43A), partial articular (43B), and intra-articular (43C), and further subclassified based on the degree of comminution. Type-III fractures are the most frequent presentation, comprising approximately 25% to 71% of all pilon fractures. Type-II fractures are defined as simple displacement without comminution of the articular surface, while type-III fractures are defined by substantial articular comminution often associated with metaphyseal impaction. In Ruedi and Allgower’s initial publication, type-I fractures were associated with the highest rate of satisfactory reduction using closed methods. Displacement is defined as greater than 2 mm of incongruity at the articular surface or mal-alignment greater than 10 degrees in any plane. Type I Ruedi-Allgower fractures are defined as nondisplaced “cleavage fractures” of the tibial plafond. The two most common classification systems used to describe pilon fractures are the Ruedi-Allgower classification and the AO/OTA classification. The vascular supply of the tibial plafond derives from branches of the anterior tibial, posterior tibial, and peroneal arteries. The tibia and fibula are held together by the interosseous membrane, anterior inferior and posterior inferior tibiofibular ligaments. This topography is designed to maximize the articular surface area with the dome of the talus and minimize the stress on the ankle joint. The distal tibia has a quadrilateral cross-sectional shape and together with the fibula, ligaments, and capsule, forms the ankle mortise. ![]() ![]() Pilon fractures may also involve metaphyseal extension and can have associated fibular fractures. These fractures account for approximately 1% to 10% of the lower leg or tibial fractures and are often associated with severe bone comminution and soft tissue compromise. Fractures of the distal tibial plafond are also termed pilon fractures to describe the high energy axial compression force of the tibia as it acts as a pestle, driving vertically into the talus. “Pilon,” the French word for pestle, was first used by Etienne Destot in 1911 as an analogy for the mechanical function of the distal tibia on the talus. ![]()
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