SUPPLEMENT ARTICLE
Contemporary Strategies in Pilon Fixation
Jonah Hebert-Davies, MD, FRCSC, Conor P. Kleweno, MD, and Sean E. Nork, MD
Summary: The treatment of tibial pilon fractures has evolved
substantially over the past decades due to ever-increasing high-
energy injuries. Open reduction and internal fixation of these intra-
articular fractures requires an appreciation for a number of basic
principles: respect the soft tissues, understand the fracture pattern,
use safe surgical approaches, and provide stability that allows for
early motion of the ankle. Surgical strategy should be customized
based on the fracture pattern, access needed for fracture visualization
Downloaded from http://journals.lww.com/jorthotrauma by BhDMf5ePHKbH4TTImqenVIF9RwgEptfl73MFmKQroaCKCcWxb5bf6QGD9z0wUy4D on 01/26/2020
and reduction, and status of the soft tissues. Given the ability to
obtain an accurate stable reduction, smaller implants are typically
adequate using multiple small incisions. We view this surgical tactic
as continuing the evolution of complex fracture treatment whose
origins lie in the influences of pioneers such as Dr Sigvard T. Hansen
Jr.
Key Words: pilon fracture, fragment-specific fixation
(J Orthop Trauma 2020;34:S14–S20)
INTRODUCTION
In general, patients’ survival rate, as well as functional
expectations, after sustaining high-energy trauma has
increased with time.1 Likewise, the treatment of tibial pilon
fractures (partial and complete articular fractures of the distal
tibia; OTA/AO classification 43-B and 43-C fracture types,
respectively2) has evolved substantially over the past decades.
These intra-articular injuries now occur with increased frac-
ture complexity, along with greater damage to the local soft
tissues.3 Consequently, the techniques of operative treatment
have had to change to meet the increasing complexity of these
injuries. The timing of definitive operative internal fracture
fixation has progressed to a staged treatment strategy,4 requir-
ing an initial period of external fixation to allow for resolution
of soft-tissue injury to decrease wound complications.1 Any
associated fibular fracture is frequently fixed early to assist
with attaining accurate limb realignment and to decrease the
overall surgical time necessary when this staged approach is
used. Currently, surgeons have a greater appreciation for frac-
ture patterns that can be treated definitively immediately
Accepted for publication November 6, 2019.
From the Department of Orthopaedics and Sports Medicine, Harborview Med-
ical Center, University of Washington, Seattle, WA.
The authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Conor P. Kleweno, MD, Department of Orthopaedics and Sports
Medicine, Harborview Medical Center, University of Washington,
Seattle, WA 98104 (e-mail: ckleweno@uw.edu).
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DOI: 10.1097/BOT.0000000000001698
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versus those patterns that are best treated with staged or mul-
tiple limited soft-tissue–friendly approaches.
ORIF of pilon fractures requires an appreciation for
a number of basic principles espoused and advanced by Dr
Sigvard T. Hansen Jr over the years. These include respect for
the soft-tissue envelope, understanding the fracture pattern in
detail, using surgical approaches that allow for a safe and
accurate fracture reduction, and attaining fracture stability that
allows for early motion of the ankle. He also emphasized the
importance of early stabilization of open fractures in the
lower limb, especially at the ankle.5
ACUTE MANAGEMENT
The acute management of pilon fractures begins with
closed reduction and application of a well-padded splint in the
emergency department. This initial treatment acts to realign the
limb, to decrease pain, and, most importantly, to stabilize and
protect the soft tissues. Particular care should be taken to assure
that there are no areas of skin at risk due to pressure from
prominent fractured bone segments. The limb is elevated, and
the patient is admitted to the hospital and optimized for surgery.
EXTERNAL FIXATION
Pilon fractures due to very low-energy mechanisms,
such as older patients with poor bone after a ground-level fall,
with simple fracture patterns (eg, some OTA/AO 43-B and
43-C1 types) can be considered for acute open reduction and
internal fixation (ORIF). However, most fractures seen at our
center are usually due to high-energy mechanisms and
associated with severe soft-tissue compromise. For these
fractures, we recommend acute external fixation and acute
fixation of the fibula (Fig. 1).
External fixation is essential to re-establish and maintain
length, alignment, and rotation. Subacute fixation of a shortened,
malaligned limb is exceptionally more difficult. External fixation
also allows for optimal soft-tissue rest while waiting for swelling
to subside. Therefore, we recommend applying an external
fixator within 24 hours after injury. In addition, we prefer
a construct with 2 pins in the tibia, a transcalcaneal pin, and
a medially based midfoot pin inserted into the cuneiforms to
keep the foot out of equinus (Fig. 1). Although there are a variety
of options for frame configuration, a key objective is to center
the talar body in line with the center of the intact tibial shaft on
anteroposterior (AP) and lateral views (Fig. 1). External fixation
objectives, as noted above, improve fracture reduction and must
avoid the common error of mistaking metadiaphyseal commi-
nution for intact tibia shaft (Fig. 2). Malreduction can cause
substantial pressure on the skin and delay the resolution of
swelling.
J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020
J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020 Strategies: Tibial Pilon Fracture Fixation

FIGURE 1. Typical high-energy pilon

fracture treated at our medical cen-
ter. The patient was involved in
a high-speed motorcycle crash sus-
taining this severe type III-B6,7 open
pilon fracture with associated talus
and calcaneus fractures. (A) Injury
film, after external fixation and acute
ORIF of fibula as shown on the AP (B)
and lateral (C) views. Note that the
talus is aligned with the intact shaft
of the tibia on both of these projec-
tions. AP, anteroposterior.

ACUTE FIXATION OF FIBULA
For C-type pilon fractures, we recommend acute fixation
of the associated fibula fracture, as long there is no severe
comminution. This is the most accurate way to re-establish the
normal length of the fractured tibia. With an intact syndesmosis,
tibial coronal plane alignment and rotation are also restored. We
recommend a posterior-lateral approach to the fibula to allow for
a sufficient skin bridge between it and the commonly used
anterolateral skin incision for subsequent tibial pilon fracture
fixation. Interestingly, no difference has been found in the
severity of C-type injuries with or without fibular fractures.8
However, the presence of a fibular fracture has been found to
be more frequently associated with C-type injury, and corre-
spondingly, an intact fibula demonstrated a significant associa-
tion with a B-type injury (P = 0.006).8
ACUTE FIXATION OF
METAPHYSEAL COMPONENTS
Certain pilon fractures extend into the diaphysis with
often simple oblique or spiral patterns, and one should
consider acute reduction and fixation of these segments.9 In

FIGURE 2. Poorly reduced high-energy pilon

fracture referred to our center after a spanning
external fixator was placed at an outside institu-
tion. Note the malreduced talus as the center of
the tibial shaft (long white line) is not in line with
the center of the talar body (short white line) on
either the AP (A) or lateral views (B). AP,
anteroposterior.

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Hebert-Davies et al J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020

this way, the fracture is converted from a complete articular
OTA/AO 43-C type pattern to a less complex, partial artic-
ular (OTA/AO 43-B type) pattern. Therefore, in some pat-
terns, this maneuver can substantially facilitate subsequent
definitive surgery.9 Although small incisions can be used
when appropriate, this is usually accomplished through
percutaneous clamps and lag screws (Fig. 3).
SURGICAL APPROACHES
The large variability in pilon fracture patterns requires
the surgeon to have knowledge of multiple approaches to deal
with each specific fracture.10 Although most fractures can be
adequately treated using one workhorse approach, it is bene-
ficial to have multiple options that allow better access to
certain fragments. Classic approaches for the pilon include
the anteromedial, anterior lateral, direct anterior, and direct
medial. The posterolateral and posteromedial approaches are
added to these to address certain fracture patterns.
Anterolateral Approach
The anterolateral approach10 skin incision is in line with
the fourth ray of the foot and extends proximally just medial
to the fibula. After skin dissection, the superficial peroneal
nerve is identified and protected. The extensor retinaculum is
then identified and incised longitudinally lateral to the pero-
neus tertius. The anterior compartment is elevated off the
distal tibia from lateral to medial, and the entire anterior tibia
is exposed. A standard longitudinal or horizontal arthrotomy
is performed to allow for visualization of the entire anterior
joint. Additional visualization of the posterior joint can be
obtained by distracting through the external fixator.
The anterolateral approach is ideal for fractures with
lateral comminution, with very small Chaput11 fragments and
those with an intact medial shoulder and a large posterior frac-
ture fragment. The small anterolateral (Chaput) fragment can be
“booked” open to allow access into the fracture and reduction of
joint impaction. The posterolateral (Volkmann) fragment can be
accessed, reduced, and stabilized to the intact tibial shaft. The
Chaput fragment is then “closed” back over top and fixed to
either the posterior fragment or the intact tibia (Fig. 4A).
Anteromedial Approach
The anteromedial approach10 skin incision starts about
1 cm lateral to the tibial crest and continues longitudinally to
the ankle join before curving medially toward the medially
malleolus or talonavicular joint. Full-thickness dissection is
used to protect the vascularity of the corner of the flap. A deep
incision is made just medial to the tibialis anterior tendon
sheath. The contents of the anterior compartment are then
elevated from medial to lateral, and the fracture is exposed.
The anteromedial approach is ideal for anterior medial
comminution and impaction, specifically within the shoulder,
and large Chaput fragments with a very medial exit. Once
impaction is addressed, the Chaput fragment can be reduced to
the medial malleolus fragment and the intact tibia (Fig. 4B).
Posterior Approaches
One of the anterior approaches can safely be combined
with one (or sometimes both) of the posterior approaches

FIGURE 3. Pilon fracture with meta-

diaphyseal extension. (A) Initial AP x-
ray, (B) intraoperative AP x-ray
showing application of a percutane-
ous clamp for reduction of the met-
adiaphyseal extension, (C) AP x-ray
after percutaneous lag screw fixation
of the metadiaphyseal segment, ORIF
of the fibula, and application of
spanning external fixation. AP,
anteroposterior.

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J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020
FIGURE 4. Examples of surgical
approach indications. (A) Axial CT
image of pilon fracture where the
anterolateral approach was used.
Note the very small remaining intact
Chaput fragment. The arrow shows
the plane that can be exploited to
debride and reduce the fragment. (B)
Axial CT view of pilon fracture where
the anteromedial approach was
used. Extensive comminution on the
medial side that is difficult to visualize
adequately from an anterolateral
approach. The arrow shows the
plane that can be exploited to debride and reduce the fracture fragments. (C) Axial CT scan cut demonstrating a horizontal
fracture line extending medially with a good reduction read proximally. This is best approached from a posteromedial approach.
(posterolateral or posteromedial)10,12 as long as soft-tissue–
friendly techniques are used. These approaches are techni-
cally easier with the patient in the prone position. However,
the posterolateral approach can be performed in the lateral or
semilateral position with a large hip bump. The posteromedial
approach can be performed with the patient supine with
a bump under the contralateral hip and the leg in a figure of
four position.
The posterolateral skin incision is made roughly halfway
between the Achilles tendon and the posterior border of the
fibula if the fibular fracture is to be addressed in the same setting.
Following skin incision, the peroneal tendon sheath is identified,
and dissection is carried medially. The Flexor hallucis longus is
elevated off the interosseous membrane and posterior tibia. The
fracture apex is located and can be booked open, allowing access
to any incarcerated or impacted pieces. The posterolateral
approach is useful in fracture patterns with a large Volkmann
fragment with a good cortical read at the apex. It is important to
obtain an anatomic reduction; otherwise, this may preclude
reduction of the Chaput and medial malleolus fragments during
the anterior approach.
The posteromedial approach is used for skin incision
between the posterior border of the tibia and the Achilles tendon.
The deep dissection can be taken directly off the posterior tibia,
just medial to the tibialis posterior or between the neurovascular
bundle and the flexor hallucis longus. Once the fracture is
located, the fragment can be opened to reveal any impaction at
the joint. Fragments extending to the extreme lateral side can be
similarly accessed; however, depending on the fracture line
orientation, these may be better addressed through a posterolat-
eral approach. The posteromedial approach is ideal to address
large posterior medial fragment or medial malleolus comminu-
tion extending posteriorly. It is also ideal to buttress posterior
malleolus variant with an anteromedial to posterolateral fracture
line orientation (Fig. 4C).
FRAGMENT-SPECIFIC FIXATION (INCLUDING
THE USE OF MINIFRAGMENT FIXATION)
Contemporary reduction and fixation of B- and C-type
tibial pilon fractures is predicated on an understanding of the
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Strategies: Tibial Pilon Fracture Fixation
fracture pattern, available surgical approaches, and predicted
secondary displacement.13 Although most pilon fractures can
be stabilized through a single surgical approach, the use of
multiple incisions that allow for fixation with smaller but-
tressing implants is often preferable.14 In general, the size
of the implants necessary for stabilization of pilon fractures
has decreased as understanding of these multiple variables has
increased. Maintenance of a well-reduced fracture is predict-
able, thus allowing fractures to be stabilized with multiple
2.0-/2.4-mm lag screws combined with small and minifrag-
ment buttressing implants without compromising stability.
Fixation of the individual columns of the distal tibia may
require larger implants (using 2.7-mm or 3.5-mm screws).
Thicker locking implants are only useful in rare circumstan-
ces where the soft-tissue envelope will not allow for implant
placement that will prevent predicted directional secondary
displacement.
This predicted secondary displacement is important for
understanding the implants necessary to stabilize the pilon
fracture. In varus failure patterns, a medial buttressing implant
is preferred, whereas, in valgus failure pilon patterns, plate
placement in an anterolateral location is optimal. In fractures
with posteromedial and/or posterolateral extension, plate
placement posteriorly is optimal to prevent shortening of
the posterior column of the distal tibia. Unfortunately, the
soft-tissue envelope will frequently dictate both the surgical
approach and the fixation strategy. Although stabilization
with a medial plate is desirable in varus failure pilon patterns,
less-rigid implants placed in a soft-tissue–friendly manner
may be preferable.15 Alternatively, thicker locking implants
may be useful, as noted above.
With partial articular injuries (OTA/AO 43-B type),
fixation consists of lag screw fixation and strategic buttressing
of the displaced fragments to the intact pillar. For example, in
an injury with an intact posterior pillar and displaced anterior
and medial fragments (Fig. 5A), the articular components are
accurately reduced, compressed with multiple individual lag
screws, and buttressed (Fig. 5B and see Figure 1, Supple-
mental Digital Content 1, http://links.lww.com/JOT/A923).
For complete articular injuries, stabilization of both
columns is required. However, the use of strategic lag screws
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Hebert-Davies et al J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020
for proximal extensions will often allow for the use of smaller
implants including minifragment implants (Fig. 6 and see
Figure 2, Supplemental Digital Content 2, http://links.
lww.com/JOT/A924). Stabilization of the reduced articular
block relative to the diaphysis can still typically be accom-
plished with a nonlocking plate.
For more complex patterns, multiple approaches may
be required. The most common combination is a poster-
omedial approach combined with an anterolateral approach.
For complex patterns with posterior comminution, postero-
lateral and posteromedial approaches may be combined with
an anterolateral approach. For fractures with a proximal
extension into the metadiaphysis, a proximal posteromedial
approach can be combined with either an anterolateral or an
anteromedial approach (Fig. 7 and see Figure 3, Supplemen-
tal Digital Content 3, http://links.lww.com/JOT/A925). The
combination of a distal posteromedial approach and an ante-
romedial approach should be avoided, as this surgical tactic
will compromise viability of the surrounding soft-tissue
envelope.16
FIGURE 5. (A) The injury lateral radiograph showing a partial
articular injury with an intact posterior pillar. (B) Postoperative
lateral radiograph after ORIF. The anterior plate at the level of
the joint is a 2.0-mm plate that functions as a washer to allow
for compression of the articular surface. These minifragment
screws have a cruciate head that allows for placement of plates
directly over the screw heads. Countersinking is typically only
required in the diaphysis, or if considerable, angulation of the
independent lag screws is required for compression. Most of
the stability of the final reduction is dependent on the com-
bination of the reduction itself and the use of multiple mini-
fragment lag screws and small low-profile plates. An
anterolateral nonlocking plate was used to complete the fix-
ation and healing proceeded predictably (See Supplemental
Digital Images online demonstrating full details of articular
reconstruction including tips from the authors).
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ADJUNCTIVE MEASURES
Several treatment adjuncts can be used to help deal with
pilon fractures, specifically those with extensive comminu-
tion. Fractures with very thin osteochondral pieces or with
severe impaction often benefit from minifragment fixation, as
described above. Although these fixation strategies offer
stable construct, even normal joint reaction forces may cause
displacement postoperatively. In these cases, the spanning
external fixator can be left on while slightly distracting the
joint and maintaining the reduction. The frame is then
removed at 4–6 weeks postoperatively either in clinic or in
the operating room. If performed in the operating room, this
opportunity can be used to perform bone grafting in cases
with extensive metaphyseal bone loss.17
In certain fractures, specifically B-type fractures with
anterior impaction of the joint, abnormal forces from the
gastrocnemius–soleus complex may be a contributory factor.
Often, the consequence after pilon fixation is a subluxated,
anteriorly translated talus. These patients generally benefit
from a gastrocnemius recession to normalize the alignment of
the talus.18 This can be achieved with a small medial incision
and then identifying the separation between the gastrocnemius
FIGURE 6. (A) Injury lateral radiograph and (B) postoperative
lateral radiograph of a C-type pilon fracture in a 28-year-man
injured in a fall from height. An anteromedial approach al-
lowed for reduction and fixation of articular surface as well as
the proximal fracture extensions. Note the fragment-specific
fixation with minifragment implants (B). The proximal ex-
tensions were first reduced and stabilized with a combination
of 2.4-mm lag screws and a 2.0-mm buttress plate.7 The
articular surface was reduced and stabilized with a combina-
tion of individual lag screws and a 2.0-mm nonlocking plate.
Finally, an anterolateral nonlocking plate was placed to stabi-
lize the articular block relative to the diaphysis, and a 1/4
tubular plate was placed medially to ensure adequate but-
tressing (see Supplemental Digital Images online demon-
strating full details of articular reconstruction including tips
from the authors).
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J Orthop Trauma  Volume 34, Number 2 Supplement, February 2020
FIGURE 7. Example of a high-energy open C-type
pilon fracture with proximal extension. (A) Initial
injury radiograph and (B) postoperative AP
radiograph. At the time of the initial irrigation and
debridement of the medial open wound, a prox-
imal posteromedial approach was performed with
the patient in the supine position combined
with a posterolateral approach for the fibula. The
proximal posteromedial fracture extension was
reduced and stabilized with multiple 2.4-mm lag
screws using the proximal posteromedial
approach. A 2.7 mm posterior buttressing plate
was placed for the tibia, the fibula was re-
constructed through a posterolateral approach,
and an ankle spanning external fixator was
placed. At 13 days, definitive fixation was
accomplished through an extensile anteromedial
exposure (see Supplemental Digital Images online
demonstrating full details of this complex articular
reconstruction including tips from the authors).
and soleus tendons. The sural nerve is protected, and the gas-
trocnemius tendon and the plantaris tendon are incised on their
entire length. This allows for neutral dorsiflexion position of the
ankle and normalization of the subluxation on the lateral x-ray
view.
CONCLUSION
An overall surgical strategy must be customized for
each pilon fracture based on the fracture pattern, the access
needed for fracture visualization and reduction, and the status
of the surrounding soft-tissue envelope. The surgical
approach (or approaches) should allow for direct reduction
of both the articular surface and any proximal cortical
extensions. Treatment is determined at the initial procedure
to allow for stabilization of any proximal extensions, acute
open anatomic reduction and internal fixation of the fibula,
spanning external fixation, and placement of incisions that do
not compromise any future incisions required for definitive
fixation. Given the ability to obtain an accurate and stable
reduction, smaller implants are typically adequate using
multiple smaller approaches. Outcomes are related to quality
of reduction,10 and one should strive to achieve an anatomic
reconstruction.
Pilon fractures continue to be challenging injuries to
treat, particularly those with high-energy, complex patterns.
Basic principles of fracture fixation championed by Dr
Sigvard T. Hansen Jr have remained relevant. Future biologic
and bioengineered solutions to cartilage damage may mitigate
the progression to post-traumatic arthritis after fracture of the
tibial pilon. However, we view this as continuing evolution of
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Strategies: Tibial Pilon Fracture Fixation
complex fracture treatment originating from the efforts of
pioneers such as Dr Hansen.
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