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Emergency Stabilization

Patients with high-energy fractures will almost always go to an urgent care center or emergency room for initial treatment because of the severity of their symptoms.

These patients may also have additional injuries to the head, chest, abdomen, or legs. If their injuries cause significant blood loss, it could lead to shock — a life-threatening condition that can result in organ failure.

Physical Examination

After discussing your symptoms and medical history, your doctor will perform a careful examination. They will:

• Examine your lower leg and ankle, looking for cuts from the injury and gently pushing on different areas to see if it hurts.
• Check to see if you can move your toes and feel things throughout your foot. In some cases, nerves may be injured at the same time that the bone is broken.
• Check your pulse at key points of the foot to be sure that there is a good blood supply to your foot and ankle.
• Check for swelling in your foot and ankle. The amount of swelling will determine if and when surgery can be done.
• Determine whether you have sustained any other injuries by examining the rest of your body. It is important to tell your doctor if you have pain in other parts of your body.

Imaging Tests

Information from imaging studies will help your doctor decide whether surgery is required and will be important for surgical planning.

X-rays. X-rays provide images of dense structures, such as bone. X-rays of the leg, ankle, and foot are commonly done to evaluate a pilon fracture. An x-ray can show if there is an injury to your bones or if the joints in your ankle are out of place.

Computerized tomography (CT) scans. A CT scan can provide valuable information about the severity of the fracture by helping your doctor see the fracture lines more clearly. A CT scan will also help your doctor plan your treatment. Your doctor may order a CT scan right away, or may wait until later in your treatment — after an external fixator is applied.

To fully evaluate your fracture, your doctor may recommend an x-ray (left), a CT scan (center), or a three-dimensional CT scan (right).

Nonsurgical Treatment

Nonsurgical treatment may be recommended for stable fractures in which the pieces of bone are not displaced or are minimally displaced.

It may also be recommended for patients who are unable to walk or patients with very serious medical problems who may not be able to tolerate surgery.

Nonsurgical treatment may include:

Splints and casts. In most cases, your doctor will first apply a splint to hold your ankle in place. Once the swelling goes down, they will replace the splint with a short leg cast. To provide effective support, your cast must correctly fit your ankle. For this reason, as the swelling in your ankle decreases, you may need frequent cast changes.

Monitoring. Your doctor will closely monitor the healing of your fracture. During this time, you will need to return regularly for follow-up X-rays to make sure your ankle remains stable.

Recovery. You will most likely be unable to bear weight on your ankle for up to 12 weeks after your injury. During this time, your doctor may recommend that you use crutches or a walker. After 6 weeks, your doctor may replace your cast with a removable brace. This will offer protection while your ankle continues to heal.

Surgical Treatment

Surgery is commonly recommended for unstable fractures in which the bones are out of place.

External Fixation

Your doctor may apply an external fixator to hold your pilon fracture in place and stabilize your ankle until your second surgery can take place.

An external fixator may be applied to protect your foot until it is safe to perform a second surgery to repair the fracture.

In this operation, your doctor makes small incisions into the skin and inserts metal pins through the bones. The pins project out of the skin and are attached to carbon fiber bars outside the skin. The external fixator acts as a frame to help hold your ankle in a good position until a second surgery can be performed. The external fixator also helps to restore proper limb length and provides stability.

Once the swelling and blisters have gone away, your doctor will perform a second surgery. The displaced bone fragments will be repositioned (reduced) into their normal alignment and held in place with metal plates and screws. The external fixator is usually removed after the plates and screws have been placed.

If your fibula is also broken, your doctor might first perform surgery to fix the fibular fracture and get your ankle back into place — and then apply an external fixator to hold your pilon fracture in place. Once the swelling and blisters go away, your doctor can then fix your tibia bone with metal plates and screws.

If your skin and bone are severely damaged, making large incisions to insert plates and screws may injure your skin further. This can result in infection. In this case, your fracture may be treated with an external fixator only or with an external fixator and some screws.

Plates and screws may be used to fix the break, as long as the skin and surrounding tissues are healthy.

Reproduced from Liporace FA, Mehta S, Rhorer AS, Yoon RS, Reilly MC: Staged treatment and associated complications of pilon fractures. Instructional Course Lecture 61. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2012, pp. 53-70.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are narcotics and can be addictive. Opioid dependency and overdose have become critical public health issues in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Early Recovery

You will most likely start moving your ankle after 2 to 6 weeks. How quickly you begin movement will depend upon your doctor's preference, the type of fracture, and the treatment used for your injury. If you have an external fixator, you may not be able to start moving your ankle until the external fixator is removed.

Because your leg and ankle will be immobilized for a period of time, you will be at greater risk for developing blood clots. To decrease your risk for a clot, your doctor may prescribe an anticoagulant, or blood thinner, while you are waiting for surgery and early on during your recovery.

Weightbearing

Most patients are not able to put all of their weight on their injured ankle for 2 to 3 months. Your doctor may recommend that you use crutches, a cane, or a walker during this time.

Physical Therapy

Once you are allowed to start moving your ankle, your doctor may place it in a removable cast or brace so that you can begin physical therapy. Specific exercises will help improve the range of motion in your ankle. Exercises to strengthen the supporting muscles will be added around 6 weeks after surgery.

As you transition to wearing regular shoes, you will gradually stop wearing your brace. By 4 months after surgery, most patients no longer need a walking aid.

Because your ankle can continue to improve for up to 2 years, it is important to continue the exercises even after you have completed the formal physical therapy program.

Infection

By delaying surgery in severe injuries, doctors have continued to decrease the risk of infection and wound problems. This risk has been brought down to about 10% or less for patients with pilon fractures.

Minor infections can be treated with antibiotics and dressing changes. More severe infections may require intravenous antibiotics for several weeks at a time. In some cases, surgery may be necessary to get rid of an infection. Very rarely, the infection cannot be cleared and amputation may be required.

Stiffness

Ankle stiffness is very common after a pilon fracture. In the majority of cases, your ankle will not be the same as it was before your injury. For example, it may be difficult to bend it the same way, go up and down stairs, or climb a ladder.

Posttraumatic Arthritis

Posttraumatic arthritis is a type of arthritis that develops after an injury. Even when your bones heal normally, the cartilage protecting the bones can be damaged, leading to pain and stiffness over time.

Some degree of posttraumatic arthritis occurs in about half of all patients with pilon fractures. Your risk for arthritis is determined by a number of factors, including the number of broken pieces of bone, the degree of displacement, and whether the bones broke through your skin (open fracture).

Some patients with posttraumatic arthritis may need further surgery to relieve symptoms. However, for some patients, there is little pain and no need for further surgery. Your doctor will develop a treatment plan based on your individual symptoms.

Bone Healing Problems

If your fracture does not heal properly, further surgery may be required. Surgery to promote healing usually includes placing a bone graft in the fracture. The bone graft will come from either your own bone (autograft) or from a donor (allograft). Sometimes, a new plate or screws may also be needed.

Other Complications

Other complications of pilon fractures may include:

• Painful plates and screws — patients who experience discomfort may choose to have their plates and screws removed after the bone has healed
• Wound healing problems
• Blood vessel or nerve damage — this may occur at the time of the injury or during surgery