Pilon Fracture (Tibial Plafond Fracture)

A pilon fracture, or tibial plafond fracture, is a relatively rare bone break (fracture) that affects the lower end of your shinbone (tibia). In many cases, your other ankle bone (fibula) is broken, as well. Pilon fractures can be challenging to treat because they involve your ankle joint, and there’s usually damage to surrounding soft tissues like skin, muscles and ligaments.

“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 it. Your tibia and fibula are attached to your talus, which is the other weight-bearing bone in your ankle. Tibial plafond fractures happen when your talus is driven into your tibia with such force that your tibia (and often your fibula) breaks at your ankle joint.

Types of pilon fractures

Healthcare providers can classify pilon fractures (tibial plafond fractures) in a couple of different ways.

Ruedi-Allgower

Under the Ruedi-Allgower classification system, providers categorize pilon fractures into 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 your tibia is displaced (not aligned), but there’s minimal or no bone fragments (comminution). A comminuted fracture is when the bone breaks into more than two pieces.
• Type III: A type III pilon fracture happens when the bone is displaced, has broken into more than two pieces, and the joint surface is in multiple pieces.

AO/OTA

Under the AO/OTA classification system, providers categorize pilon fractures as:

• Extraarticular (43A)
• Partial articular (43B)
• Complete articular (43C)

Then, they subclassify the fracture based on the degree of comminution.

Symptoms of pilon fractures

Tibial plafond fractures are often severe injuries that can cause intense pain in your lower leg and ankle. The injury can be extremely uncomfortable and affect your ability to walk.

Other pilon fracture symptoms may include:

• Bruising, swelling and/or tenderness around your lower leg and ankle
• Crooked or deformed-looking ankle
• Inability to put weight on your injured leg
• Skin blisters around your lower leg and ankle

Pilon fracture causes

Most pilon fractures happen when your talus is driven into 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 tibial plafond fractures, including:

• High-impact events, like car accidents, falls from significant heights and skiing accidents
• Bone-weakening diseases, like osteoporosis, that contribute to these fractures from low-impact events like minor falls

Risk factors for tibial plafond fractures

Anyone can experience a pilon fracture at any age, but certain people are more likely to have one:

• Males between the ages of 25 and 50 are more likely to get a pilon fracture from a high-impact event, like a car accident.
• Females who have osteoporosis are more likely to get a tibial plafond fracture from a low-impact event, like a minor fall.
• People who use ladders or work on roofs are more likely to experience a pilon fracture due to the chance of falls.
• People who have a history of falls, especially people over the age of 65, are more likely to experience a pilon fracture from falling.

Complications of pilon fractures

Your risk of complications from a tibial plafond fracture depends on how severe the fracture is and whether you had other injuries. Complications may include:

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

How doctors diagnose pilon fractures

An orthopedic surgeon will do a physical exam of your leg and ankle and ask you about your symptoms. They’ll need to see an X-ray to diagnose a pilon fracture (tibial plafond fracture). They may request additional imaging tests to learn more about your injury.

Imaging tests that your provider may use to diagnose a tibial plafond fracture include:

• X-rays
• CT scan

How is a pilon fracture treated?

Treatment for a tibial plafond fracture depends on several factors, including:

• The number of fractures
• The pattern and type of the fracture
• Whether the bones are displaced (not aligned), and how much they’re displaced
• If surrounding soft tissues — like skin, muscles and tendons — are damaged
• Your overall health and whether you have other injuries

Nonsurgical treatment

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

• Rest: Your healthcare provider will most likely recommend that you rest as much as possible with your affected leg elevated.
• Cast, splint or boot: Your provider will likely have you wear a cast, splint or boot as your fracture heals to stabilize your ankle.
• Walking aids: Your healthcare team may have you use a walking aid, like crutches, to avoid bearing weight on your affected leg.
• Medications: Your provider may prescribe a blood thinner (anticoagulant) to reduce your risk of blood clots forming in the veins of your leg.
• Physical therapy: Your provider may recommend physical therapy to restore strength in your leg and ankle after your fracture has healed.

Surgical treatment

If you have a pilon fracture that’s displaced and the bones aren’t aligned properly, you’ll likely need surgery. Depending on the severity of your fracture and whether you have other injuries, your orthopedic surgeon may delay your surgery until the swelling around your ankle has settled. They need to make sure you’re healthy enough to have the surgery to minimize risks, like an infection. Types of pilon fracture surgeries include:

• Open reduction and internal fixation: Your orthopedic surgeon repositions the displaced bone fragments 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.
• External fixation: Your surgeon inserts metal pins through your bones. The pins stick out of your skin and are attached to bars outside 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.

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

The length of time it takes for a tibial plafond fracture to heal depends on the severity and whether you had other injuries. Most pilon fractures require surgery. It usually takes three to six months for the fracture to heal completely after surgery. But it often takes a year or more to fully recover from the injury.

When should I see my healthcare provider?

If you’re experiencing signs and symptoms of a pilon fracture, see a healthcare provider right away. If you can’t get to urgent care or an emergency room on your own, call 911 or your local emergency number for help.

If you had surgery to fix the pilon fracture and are experiencing signs of infection — like redness, pus or warmth at your surgical site — go to the nearest hospital as soon as possible.

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 surface itself and the surrounding soft tissues, like muscles and ligaments. It can take a year or more to fully recover from the injury, and long-term ankle arthritis, stiffness and swelling are common following a pilon fracture.

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 and prevent getting a pilon fracture, including:

• Driving 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.
• Following 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.
• Using 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. This could prevent you from getting a pilon fracture.