[Pilon Tibial Fractures - What Can We Achieve?]

Pilon fractures, as intra-articular fractures of the distal tibia involving the ankle joint, represent one of the most challenging injuries in trauma surgery. This review analyzes current treatment concepts and their outcomes based on a narrative review. Pilon fractures account for 3-10% of all tibial fractures and typically result from axial compression mechanisms in high-energy trauma or torsional forces in low-energy injuries. The complex anatomy of the tibial plafond with its limited vascular supply and thin soft tissue coverage considerably complicates treatment. Established classification systems such as the Rüedi-Allgöwer and AO classifications enable systematic fracture analysis, while the Tang 4-column classification supports anatomically oriented surgical approach planning. Surgical management often follows a staged concept, with initial external fixator stabilization and definitive reconstruction after soft tissue consolidation. Multiple surgical approaches according to the 4-column anatomy allow targeted fragment stabilization, with locking plate osteosynthesis representing the standard procedure. Intraoperative 3D imaging has become indispensable for assessing articular congruence. Despite technical advances, complication rates remain high, at up to 50%, and are dominated by wound healing disorders, infections, and post-traumatic arthritis. Functional outcomes show significant limitations with AOFAS scores between 50 and 82 points depending on fracture type and treatment method. At 57%, the return-to-work rate is dramatically limited. Complex AO type C fractures develop post-traumatic arthritis in more than 50% of cases with corresponding long-term consequences. Pilon fractures require an individualized, multidisciplinary treatment strategy with realistic prognostic communication regarding expected functional limitations and occupational consequences.