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

Abstract

Introduction Controversy exists around which distal tibial fractures are pilon fractures. We evaluated views to define a pilon fracture and support the development of standards of care. Methods Views regarding the characteristics of a pilon fracture and acute soft tissue management were determined through a questionnaire. This was trialled, approved by the British Orthopaedic Foot and Ankle Society and distributed to its members. This was also distributed nationally as part of the ENFORCE study. Results In total, 282 consultants from 27 units responded, of whom 24% (69/282) were foot and ankle specialists. Some 58% (163/282) agreed that a pilon fracture is primarily a soft tissue injury, 81% (228/282) that pilon fractures occur though high-energy transfer, 81% (228/282) that pilon fractures are sustained through an axial compression mechanism and 93% (265/282) that they are a potentially limb-threatening injury. Overall, 83% (234/282) agreed that in a length-unstable pilon fracture it is not possible to maintain the talus near anatomically under the tibial plafond without rigid fixation to control length – with 87% (246/282) agreeing that the acute first-line management should be a spanning external fixator. Opinions were that the time frame between diagnosis and intervention should be: less than 6h (63%; 154/246), 6–12h (31%; 77/246) and 12–24h (6%; 15/246). Conclusion Consensus supports defining a pilon fracture as a potentially limb-threatening high-energy axial compression injury, and a spanning external fixator as the first-line management of a length-unstable injury less than 12h from diagnosis.