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trauma

Pilon Fracture

advanced
6 min
26 marks
6 questions
Clinical Scenario
A 35-year-old rock climber presents after falling 4 metres, landing on his feet. He has severe right ankle pain with marked swelling and fracture blisters. The foot is neurovascularly intact but compartments feel tense. He also reports bilateral heel pain and low back pain.
AP and lateral ankle radiographs showing comminuted distal tibial articular fracture (pilon) with significant metaphyseal comminution and impaction. Associated fibular fracture at same level indicates high-energy mechanism. CT 3D reconstruction shows articular surface fragmentation.
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AP and lateral ankle radiographs showing comminuted distal tibial articular fracture (pilon) with significant metaphyseal comminution and impaction. Associated fibular fracture at same level indicates high-energy mechanism. CT 3D reconstruction shows articular surface fragmentation.

Source: Operative Treatment of Complex Pilon Fractures • PMC3796922 • CC-BY

Questions

Question 1 (4 marks)

What associated injuries must you assess for with this mechanism?

Question 2 (4 marks)

Classify this fracture and describe the key imaging features.

Question 3 (5 marks)

Describe your initial management and the rationale for staged surgery.

Question 4 (6 marks)

Describe the surgical approaches and fixation technique for definitive ORIF.

Question 5 (4 marks)

What complications would you discuss with this patient?

Question 6 (3 marks)

What are the prognostic factors and expected long-term outcomes?

Exam Day Cheat Sheet

Must Mention

  • •Axial loading → check spine (10%) and calcaneus (10%)
  • •Ruedi-Allgower classification (I = minimal, II = displaced, III = comminuted)
  • •Staged approach: ex-fix → wrinkle test → definitive ORIF
  • •Wrinkle test timing: 10-21 days
  • •Wound complications up to 40% with early ORIF; <10% with staging
  • •Ruedi sequence: fibula → articular → bone graft → metaphysis

Common Pitfalls

  • •ORIF before wrinkle test (wound complications)
  • •Missing calcaneus/spine injuries (10% each)
  • •Operating through blood-filled blisters
  • •Not using staged approach for high-energy Type III
  • •Inadequate articular reduction (>2mm step = worse outcome)
  • •Missing compartment syndrome