[Strategies for the definitive management of pilon fractures]

Pilon fractures are among the most challenging injuries of the lower extremities and are associated with a high complication rate due to the frequently severe soft tissue damage. The currently established 2‑stage treatment concept with initial stabilization using a joint-bridging external fixator, subsequent soft tissue conditioning and thorough preoperative planning represents the current gold standard of care. Computed tomography with multiplanar and three-dimensional reconstruction is indispensable for detailed analysis of the fracture morphology and the development of an individually adapted surgical strategy. Typically, three major fragments can be identified: the anterior, medial and posterior fragments. A thorough understanding of key anatomical structures, particularly the ligamentous attachments and potential soft tissue interposition, is essential for selecting the optimal reduction strategy and surgical approach. The primary goal of surgical treatment is anatomical reconstruction of the articular surface while preserving the surrounding soft tissues as much as possible. Despite advances in implant technology, the treatment principles originally described by Rüedi and Allgöwer remain the cornerstone of operative management. In complex complete articular fractures (type C), reconstruction can often be simplified by functionally converting the fracture into a type B or type A pattern before definitive fixation. Modern stabilization techniques should be tailored to both fracture morphology and the condition of the soft tissues while adhering to the principles of biological osteosynthesis. A structured treatment algorithm based on meticulous preoperative planning, anatomical joint reconstruction and careful soft tissue management is essential to minimize complications and optimize long-term functional outcomes.