Pilon Fractures

What is a pilon fracture?

A pilon fracture is a relatively rare bone break that happens at the bottom of your tibia (the larger of the two bones in your lower leg, or your shinbone) near your ankle. In many cases of pilon fractures, the other bone in your lower leg, your fibula, is broken as well. Most cases of pilon fractures are caused by high-impact events, such as a vehicle accident or falling from a significant height.

“Pilon” is the French word for pestle, which is a tool with a rounded end that’s used to crush and grind substances. This type of bone break is called a pilon fracture because of the crushing force that often causes them. Your tibia and fibula are attached to your talus, which is the weight-bearing bone in your ankle. Pilon fractures happen when your talus is driven into your tibia with such force that your tibia (and often your fibula as well) breaks at your ankle joint.

What are the different types of pilon fractures?

There are several types of pilon fractures depending on the pattern of the break, and there are many classification systems to describe them. Under the Ruedi-Allgower classification system, healthcare providers categorize pilon fractures as the following types:

• Type I: A type I pilon fracture is an articular fracture (bone break in or around a joint) with minimal or no bone displacement (the broken bones are still aligned).
• Type II: A type II pilon fracture happens when the bottom of the tibia (known as the articular surface of the bone) is displaced (not aligned), but there’s minimal or no fragments (communition). A comminuted fracture is when the bone breaks into more than two pieces.
• Type III: A type III pilon fracture happens when the bone has broken into more than two pieces (comminution) and the ends of the broken bones have driven into each other (impacted fracture). Approximately 25% to 71% of pilon fractures are type III fractures.

There are also types of fractures that can apply to any bone break. Your healthcare provider may use one or more of the following terms to describe your pilon fracture:

• Closed or open (compound) fracture: If the fracture doesn’t break open the surrounding skin, it’s called a closed fracture. If the broken bone pierces through the skin, it’s called an open fracture or a compound fracture. Approximately 20% of pilon fractures are open fractures.
• Complete fracture: A complete fracture happens when the bone breaks into two pieces.
• Displaced fractures: A displaced fracture means the broken bones do not stay aligned like they normally would be.
• Comminuted fracture: A comminuted fracture means the bone breaks into more than two pieces.
• Impacted fracture: An impacted fracture happens when the ends of the broken bone are driven into each other.
• Spiral fracture: Spiral fractures happen when the fracture spirals around the bone.

How serious is a pilon fracture?

Pilon fractures can be challenging to treat because they involve the ankle joint and there’s usually damage to surrounding soft tissues such as muscle, skin and ligaments. Approximately 20% of pilon fractures are open fractures, which means the broken bone has pierced through the skin. Open fractures can lead to infection, which can be dangerous. Pilon fractures are often severe injuries that can cause long-term issues, such as arthritis in your ankle joint.

Who gets pilon fractures?

Anyone can experience a pilon fracture at any age. Males between the ages of 25 and 50 are more likely to get a pilon fracture from a high-impact event such as a vehicle accident. Older females who have osteoporosis are more likely to get a pilon fracture from a low-impact event such as a minor fall.

How common are pilon fractures?

Pilon fractures are relatively rare. Approximately 1% to 10% of lower leg or tibia fractures are pilon fractures.

What are the symptoms of a pilon fracture?

Signs and symptoms of a pilon fracture can include:

• Experiencing intense pain in your lower leg and ankle.
• Having bruising, swelling and/or skin blisters around your lower leg and ankle.
• Not being able to put weight on your injured leg.
• Having an ankle that appears crooked or deformed.

What causes the condition?

Most pilon fractures happen when your talus (the weight-bearing bone in your ankle) is driven into your lower leg bone(s) (your tibia and fibula) with such force that your leg bone(s) breaks at your ankle joint. There are a few situations or conditions that can cause pilon fractures, including:

• High-impact events: The majority of pilon fractures are caused by high-impact events such as a car accident, falling from a significant height and skiing accidents.
• Bone-weakening diseases: Bone-weakening diseases such as osteoporosis can contribute to pilon fractures. If an individual has osteoporosis, they could get a pilon fracture from a low-impact event such as a minor fall. These kinds of pilon fractures are rare.

How are pilon fractures diagnosed?

Pilon fractures require X-rays in order to be diagnosed. Your healthcare team may have you undergo other imaging tests to learn more about your injury.

What tests are used to diagnose pilon fractures?

The following imaging tests can be used to diagnose a pilon fracture:

• X-rays: X-rays use radiation to take images of your bones. All pilon fractures require X-rays so that your healthcare team can see the type of pilon fracture you have, how severe it is and so they can learn how the fracture needs to be treated.
• CT scan: A CT (computed tomography) scan uses multiple X-rays taken from different angles of your body to produced detailed images. A CT scan provides more detailed images than regular X-rays do. Your healthcare team may have you undergo a CT scan to learn more about your pilon fracture as a preparation for surgery.

How is a pilon fracture treated?

Treatment for a pilon fracture depends on several factors, including:

• The number of fractures.
• The pattern and type of the fracture.
• If the bones are displaced (not aligned) and how much they’re displaced.
• If surrounding soft tissues, such as muscle, tendons and skin, are damaged.
• Your overall health and if you have other injuries.

If you have a pilon fracture that isn’t displaced and your bones are still aligned properly, you may not need surgery. Non-surgical treatment for pilon fractures can include:

• Rest: Your healthcare provider will most likely recommend that you rest as much as possible with your affected leg elevated so that you don’t put extra pressure on your pilon fracture.
• Casts, splints and/or boots: Your healthcare team will likely have you wear a splint, cast and/or boot as your fracture heals to stabilize your ankle.
• Walking aids: Your healthcare team may have you use a walking aid such as crutches to avoid bearing weight on your affected leg. You may have to use the walking aid for up to three months or until your pilon fracture is fully healed.
• Medications: Your healthcare provider may have you take a blood thinner medication (anticoagulant) to reduce your risk of having blood clots form in the veins of your legs.
• Physical therapy: You may have to go through physical therapy to restore strength in your leg and ankle after your fracture(s) has healed.

If you have a pilon fracture that is displaced and the bones aren’t aligned properly, you’ll likely need surgery. Depending on the severity of your fracture and if you have other injuries, your healthcare team may delay your surgery until the swelling around your ankle has settled and you are healthy enough to undergo surgery to minimize risks such as infection. Types of surgeries used to treat pilon fractures include:

• Open reduction and internal fixation: During open reduction and internal fixation surgery, the displaced bone fragments are first repositioned into their normal alignment. The fragments are then held together with screws or metal plates that are attached to the outer surface of the bone. Your surgeon can only do this kind of surgery to fix your break if your surrounding skin and tissues are healthy.
• External fixation: In this surgery, your surgeon makes small incisions (cuts) into your skin and inserts metal pins through your bones. The pins stick out of your skin and are attached to bars outside of your body. The external fixator acts as a frame to help hold your ankle in a stable and secure position until your surgeon can perform a second surgery (usually open reduction and internal fixation) to fix your fracture.

Post-surgery treatment for pilon fractures can include:

• Medication: Your healthcare provider may have you take blood thinner medication (anticoagulants) to help prevent blood clots from forming in your legs.
• Rest: You will have to rest a lot after your surgery so that your bones and incisions can heal. Your ankle will likely be immobilized in a cast for six weeks or more after surgery. Be sure to follow your healthcare team’s instructions for rest and movement.
• Physical therapy: Once you’re allowed to start using your ankle, your provider may put it in a removable cast boot or brace so that you can begin physical therapy. Specific exercises will help improve the strength and range of motion in your ankle.

People who experience a pilon fracture from a high-impact event such as a car accident often have other injuries that will also need to be treated. In these cases, the success in treating the pilon fracture often depends on the success of treating the related injuries.

How long does it take a pilon fracture to fully heal?

The length of time it takes for a pilon fracture to heal depends on the severity of the injury and if the individual had other injuries from the event that caused the pilon fracture. Most pilon fractures require surgery. It usually takes three to six months after surgery for the fracture to heal completely. However, it often takes individuals a year or more to fully recover from the injury.

What are the risk factors for getting a pilon fracture?

Some risk factors for getting a pilon fracture include:

• Using a ladder: Falls off a ladder or roof (and automobile collisions) are common causes of pilon fractures.
• Osteoporosis: Although pilon fractures caused by low-impact events like a minor fall aren’t that common, people who have osteoporosis are at a higher risk of experiencing a pilon fracture from a low-impact event.
• A history of falls: People who have a history of falls, especially older people, are more likely to experience a pilon fracture from falling.

How can I prevent getting a pilon fracture?

Depending on your age and lifestyle, there are a few things you can do to try to prevent getting a pilon fracture, including:

• Drive safely: High-impact vehicle accidents are a common cause of pilon fractures. Always practice safe driving and follow traffic laws. Avoid distractions while you’re driving.
• Follow ladder safety instructions: When you’re using a ladder, be sure you’re doing so properly and safely. Always make sure your ladder is in a secure position before using it.
• Use a walking aid if you’re at a higher risk of falling: Using a walking aid such as a cane or a walker can help prevent you from falling, which could prevent you from getting a pilon fracture.

What is the prognosis (outlook) for a pilon fracture?

Despite advances in imaging technology and surgical approaches, pilon fractures are challenging to treat. This is because pilon fractures often cause damage to the ankle joint itself and the surrounding soft tissues such as muscle and ligaments. It can take individuals a year or more to fully recover from the injury, and long-term ankle arthritis is common following a pilon fracture.

Are there complications associated with having a pilon fracture?

Your risk of complications from your pilon fracture depends on how severe the fracture is and if you had other injuries from the event that caused your pilon fracture. Complications caused by a pilon fracture can include:

• Soft tissue damage, including muscle, skin, ligaments, tendons, blood vessels and nerves.
• Infection.
• Decreased mobility.
• Joint stiffness.
• Post-traumatic arthritis in the affected bones and joint.
• Chronic pain.

When should I see my healthcare provider?

If you are experiencing signs and symptoms of a pilon fracture such as intense pain in your lower leg and ankle and having a crooked or deformed ankle, see a healthcare provider right away. If you can’t get to urgent care or an emergency room on your own, call 911 for help.

If you had surgery to fix your pilon fracture and are experiencing signs of infection, such as having redness, pus or warmth at your surgical wound or having a fever, go to the nearest hospital as soon as possible.

A note from Cleveland Clinic

While pilon fractures are rare, they can be serious injuries. Know that your healthcare team will help you along the way to your recovery. Don’t be afraid to ask questions about your injury and treatment plan. They are there to help you.