Figure 1. Anteroposterior radiograph of ankle.
Figure 2. Lateral view of the ankle.
A 36-year-old man presents to the emergency department with severe right leg pain after falling off the top of an 8-foot ladder. He reports losing his balance and landing directly on his right leg when he hit the ground. On physical examination, he has an obvious deformity to the right distal tibia but the skin and soft tissues remain intact. He has a moderate amount of swelling around the distal tibia and his distal pulses are intact. Radiographs are ordered (Figures 1 and 2). He smokes at least 1 pack of cigarettes a day but is otherwise healthy and denies taking any prescription medications.
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A tibial pilon fracture, also known as a tibial plafond fracture, is a distal tibial fracture commonly associated with comminution, intra-articular extension, and soft tissue compromise. Pilon fractures are often a result of a high-energy axial force on the leg such as a fall from a significant height or a motor vehicle accident.
Initial diagnostic workup includes radiographs to include the entire tibia and foot/ankle. Computed tomography scan (CT) is also critical in determining articular involvement and preoperative planning. The scan is often performed after an external fixator is placed as pulling the fracture to length for the scan can shift the fracture.1,2
Pilon fractures frequently present with significant soft tissue swelling and injury (fracture blisters, skin breakdown), which leads to high complication rates when these fractures are treated with early open reduction and internal fixation (ORIF). A common treatment protocol for high-energy, comminuted, and displaced pilon fractures includes closed reduction with placement of an external fixator for initial restoration of length and alignment. Once the soft tissue swelling has diminished and all fracture blisters or open wounds have healed, definitive ORIF can be performed. Open reduction performed around the 2-week mark after external fixation results in improved surgical wounds with fewer complications.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Kottmeier SA, Madison RD, Divaris N. Pilon fracture: preventing complications. J Am Acad Orthop Surg. 2018;26(18):640-651. doi:10.5435/JAAOS-D-17-00160
2. Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13(2):78-84. doi:10.1097/00005131-199902000-00002