Physical Therapy Videos - Foot & Ankle
Basic Anatomy
A pilon fracture is an injury of the ankle joint. The ankle is made up of the bottom end of the tibia bone, the talus bone, and the fibula bone. The talus is the bone just below the tibia, or “shin bone.” The fibula is the smaller bone on the outside of the ankle. These bones are lined with a smooth, low-friction substance called cartilage. This cartilage allows the ankle joint to move smoothly. Ligaments connect bones to bones and hold them together. In the ankle, there are also arteries, veins, and nerves that connect to the muscles and skin of the foot. These run on the inside of the ankle, the outside of the ankle, and in the front of the ankle.
Mechanism and Epidemiology
The pilon is part of the shinbone (tibia) and makes up one part of the ankle joint. A pilon fracture is a break (fracture) of the bottom end of the tibia. A pilon fracture can range from a single crack to a more severe injury with the bones shattering into many pieces. Pilon fractures usually happen after accidents like falls, car crashes, or industrial work accidents. Pilon fractures tend to be worse than a simple ankle fracture. At the time of the accident, the talus bone drives into the end of the tibia and fibula and splits them like a wedge.
Initial Treatment
After a pilon fracture, the ankle will likely be too painful to walk. The ankle may look crooked, bent, or out of place. You will likely need to go to an emergency room. Healthcare providers will take x-rays of the ankle and leg. They may also try to set the bones back into place. You will be placed in a splint. You will not be able to walk on your injured leg.
Most pilon fractures are so bad that an early surgery is needed to hold the bones in the right spot. You may be brought to the operating room to put on an external fixator. An external fixator is a special device made of pins, bars, and clamps used to hold the bones. Multiple pins are placed into the tibia, heel bone (calcaneus), and other bones in your foot. The pins will have clamps and bars attached to keep the bones stable. This device is used for several weeks to let the swelling heal before your final surgery.
Sometimes the ankle can swell so much that you develop fracture blisters. These are blisters around the ankle that can fill with yellow fluid or even blood. It is important to keep the skin at the blister area clean and dry. The blisters may pop on their own, and if so you should let your surgeon know. If they look like they are getting red, hot, more painful, or possibly infected, you should tell your surgeon right away. Fracture blisters generally take a few weeks to heal. You may be instructed on how to change your bandages to keep them healing well.
After a pilon fracture, you may be admitted to the hospital to check on your swelling and pain. Sometimes there can be too much swelling, which can lead to further injury of the muscles and nerves of the leg.
General Treatment
Depending on what doctors see in your x-rays, your fracture may be treated with or without surgery. Your surgeon will talk to you about the options and help you decide the best way to treat your fracture. Most pilon fractures need 6 to 12 weeks without weight in order to heal. After this time, you will slowly start to put more and more weight on your leg. You may be sent to a physical therapist to ensure are walking normally.
Most pilon fractures need surgery to permanently line up the bones. Your surgery team will help determine when your leg is safe for surgery. It may take a couple of weeks for the swelling go down enough for surgery. At the time of surgery, your surgeon will make several incisions (cuts) on your skin to line up the bones and to hold them in the right spot with plates and screws. These incisions can be placed on the inside, outside, front, or back part of your ankle. Your surgeon may also talk to you about using extra bone from you or a donor to help fix the break.
Some pilon fractures are “open" or "compound,” meaning the bone stuck through the skin at the time of injury. In those cases, or if there is a problem with the skin or wound healing, a plastic surgeon may be needed to help close the wound. Sometimes skin grafts or flaps (taking skin, muscle, or tissue from another area and putting it on the wound) may be needed.
Postoperative Care
Your surgeon will require you to keep weight off your leg for many weeks after a pilon fracture. This means no walking or pushing with your leg. This is important to let the bones heal. Most pilon fractures need 6 to 12 weeks to heal. Your surgeon or physical therapist may give you crutches, a wheelchair, a knee scooter, or other devices to help you get around safely and without weight.
After surgery, you will likely be in a splint or brace for at least 2 weeks. After that point, your stitches will be removed, and you may be placed into a cast or another brace. Your rehabilitation team may allow you to move your ankle soon after your surgery. Most patients do not put weight for 12 weeks after surgery, but this is dependent on the type of fracture and how it was treated. Be sure to discuss this with your surgical team. Patients generally come back to clinic about 6 weeks and 12 weeks after surgery to check healing and motion, and take more x-rays.
To reduce the risk of complications, it is very important to follow the instructions of your surgeon. These instructions may include keeping weight off the leg, elevating the leg, or doing some gentle exercises to help with healing and prevent stiffness. Complications like wound healing issues or infections can be very difficult in pilon fractures.
Long Term
Pilon fractures severely injure the cartilage in and around your ankle. This injury to the cartilage can cause arthritis, and arthritis may take years to develop. Patients may have stiffness, pain, swelling, and a hard time standing or walking for a long period. To help reduce pain and improve function, some patients may need braces or more surgery, such as an ankle replacement or fusion. A pilon fracture can be very disabling and may cause long-term problems and pain in the ankle. If there are wound healing problems, infection, or the bones does not heal, you will likely require more surgery, or in some extreme cases an amputation.
If you have a job that requires you to be on your feet a lot, a pilon fracture will significantly affect your life at least in the short term. It may be important to see if your job can be modified so you can do less walking or standing. If that is not possible, you may need to consider options that require less walking and standing.
Physical Therapy Videos - Foot & Ankle
More Information
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Eric Magnuson, MD, and Christopher Domes, MD
Edited by the OTA Patient Education Committee
X-rays and images from the personal collections of Dr. Magnuson, Dr. Domes, and Matthew Hogue, MD