Fractures Of the Tibial Plateau (Tibial Pilon)

Tibial pilon fractures are distal tibial fractures with involvement of the articular facet. It is established that this is a traumatic injury of the distal end of the tibia involving the epiphysis and metaphysis, with a complex articular fracture, collapse of one or more fragments, and significant soft tissue involvement. Distal tibial pilon fractures encompass a wide range of injury mechanisms, patient demographic characteristics, and combined soft tissue and bone injuries [1]. Tibial pilon fractures account for less than 10% of lower extremity injuries, 7-10% of tibial fractures, and 1% of lower extremity fractures. The average patient age is 35-40 years, with a predominance of men under 50 years of age and women in their fifth decade of life. They are bilateral in 5-10% of cases, and the incidence of open fracture is 20-25% [2]. The most common injury mechanisms are automobile collisions and falls from a height; the cause of the injury is generally axial loading of the talus on the pilon. This is a serious fracture, highly technically demanding, and has a high risk of complications, sequelae, and poor outcomes [3]. The purpose of this article is to briefly review tibial pilon fractures.

Search Strategy and Selection Criteria

References were identified by searching PubMed, Google Scholar, and Elsevier for publications published between 2013 and 2025 in English using the terms «tibial pilon fractures,» «fractures of the distal end of the tibia,» and «metaphyseal-articular fractures of the distal tibia.» Articles accessible either freely or through the Clinical Key and Hinari services were also reviewed.

Development

Tibial pilon fractures have different trajectories in the cartilage of the distal tibia. These fractures may involve impaction of the anterior or posterior articular surface, or both, as well as central impaction, depending on the direction in which the traumatic forces act. Careful analysis of the direction and orientation of the fracture pattern is essential for determining the best surgical approach. There is no universally accepted classification of tibial pilon fractures. Important characteristics to consider include articular and metaphyseal fragmentation, shortening of the tibia due to proximal displacement of the talus, impaction of one or more articular fragments, and associated soft tissue injuries. This results in a wide variation in fracture patterns, depending on the position of the foot and the direction and magnitude of the applied force [4]. The Rüedi-Allgöwer classification, of historical value, considers three types of tibial pilon fractures. In this classification, fragmentation and displacement refer to the articular surface; the AO/OTA classification system is more precise than the previous one. The Tscherne classification is used to grade soft tissue involvement [5].

A systematic and periodic assessment should be performed to look for associated injuries, which are very common, and soft tissue involvement (edema, wounds on the inner surface of the distal tibia or at the level of the fibula fracture, hyperpressure and cutaneous necrosis, abrasions, contusions, hematomas, neurovascular status, or possible compartment syndrome). Imaging studies, including x-rays and CT, are essential for adequately assessing fractures and allowing for planning surgical intervention. Nonsurgical treatment is rarely used for tibial pilon fractures. Its indications are stable fractures without displacement of the articular facet or patients who are unable to ambulate or those with significant neuropathy [6]. Surgical treatment depends on the degree of soft tissue injury, the pattern or «personality» of the fracture (comminution and joint involvement), and the surgeon’s experience. As these are usually high-energy fractures, with if soft tissue involvement is present, a two-stage treatment is preferred: initial treatment with an external fixator prior to definitive treatment; calcaneal traction if reduction cannot be maintained, with a 4.5 kg weight, or reduction and immobilization with a cast if the fracture is very slightly displaced.6 Surgical treatment is technically very difficult and is indicated for complex fractures only when the soft tissue is identified: palpable bony prominences, skin folds (fold or wrinkle sign), and absence of hemorrhagic phlyctenas. The incisions to be used must be carefully planned to restore the articular surface, ensuring solid fixation to allow for early mobilization. It can be performed with plates and screws, Kirschner wires, and/or an external fixator. The approach depends on the displacement of the largest fragment. It is usually anterolateral or anteromedial. A modified anteromedial approach has recently been described, allowing visualization of the anterolateral area. In some cases, a posteromedial approach may be useful [7,8]. The Frequent complications include post-traumatic osteoarthritis, wound dehiscence, infection, pseudoarthrosis, joint stiffness, malunion, osteomyelitis, or complex regional pain syndrome.

Tibial pilon fractures present an immense challenge for orthopedic surgeons. Preoperative planning is essential and includes thorough clinical investigation and imaging studies. Special consideration and care must be taken in the management of the fragile soft tissue envelope surrounding tibial pilon fractures. Selecting the appropriate therapeutic approach for each fracture pattern is important to achieve the best outcome and reduce the incidence of complications.

None.

No conflict of interest.

1. Hill DS, Davis JR (2023) What is a tibial pilon fracture and how should they be acutely managed? A survey of consultant British Orthopaedic Foot and Ankle Society members and non-members. Ann R Coll Surg Engl 107(6).
2. Luo TD, Pilson H (2022) Pilon Fracture. PubMed. Treasure Island (FL): StatPearls Publishing.
3. Rodriguez Castells F (2020) Fracturas del pilón tibial. Rev Asoc Arg Ortop y Traumatol 61(3): 312-321.
4. Murawski CD, Mittwede PN, Wawrose RA, Belayneh R, Tarkin IS (2023) Management of high-energy tibial Pilon fractures. J Bone Joint Surg Am 105(14): 1123-1137.
5. Mair O, Pflüger P, Hoffeld K, Braun KF, Kirchhoff Ch, et al. (2021) Management of Pilon Fractures. Current Concepts. Front. Surg.; 8:764232.
6. Lineham B, Faraj A, Hammet F, Barron E, Hadland Y, et al. (2024) Outcomes Of Acute Ankle Distraction For Intra-Articular Distal Tibial And Pilon Fractures. Orthop  Procs 106-B(Supp5): 11-11.
7. Mombello F, Vera G, Rammelt S (2024) Pilon Fractures: Update on treatment. J Foot Ankle18(3): 274-291.
8. Das M, Pandey S, Gupta H, Bidary S, Das A (2023) Clinical characteristics and outcome of tibial pilon fractures treated with open reduction and plating in a tertiary medical college. Journal of Gandaki Medical College 16(2).