[Acute management of pilon fractures]

Pilon fractures are complex injuries involving the weight-bearing articular surface of the distal tibia and are frequently associated with relevant soft tissue damage. The treatment requires a structured strategy in which the condition of the soft tissues plays a central role. These fractures result either from low-energy rotational injuries or high-energy axial compression trauma. While the former typically occur in older patients and are associated with limited soft tissue injury, the latter often lead to complex fracture patterns with severe articular impaction and metaphyseal comminution. Nowadays, a 2-stage treatment concept is considered the gold standard. Initial management consists of the placement of a joint-spanning external fixator to restore length, alignment and rotation while enabling relief of the soft tissues. Subsequently, computed tomography diagnostics and preoperative planning are performed according to the principle of span-scan-plan. Open fractures require immediate intravenous antibiotic administration, meticulous debridement and removal of avascular bone fragments. In cases of critical soft tissue conditions, early involvement of plastic surgeons is recommended. Soft tissue-threatening or irreducible fracture fragments must be addressed with minimally invasive techniques during the initial treatment phase. In contrast, emergency primary fibular osteosynthesis is generally not recommended as it can compromise subsequent anatomical reconstruction of the tibial plafond. Management of the fibula should usually be performed in conjunction with the definitive osteosynthesis of the pilon fracture. Successful treatment depends not only on precise osseous reconstruction but also above all on meticulous soft tissue management.