Overview
Operating on a limb with minimal swelling and a good soft-tissue envelope is essential to avoid complications. Skin wrinkling is a reliable sign that the edema has resolved. Handle the soft tissues meticulously; strict "no-touch" techniques have been advocated. The safest course is to temporize with an external fixator until the soft tissues allow definitive fixation.
Be cautious with formal open plating in open fractures and Rüedi–Allgöwer type III (AO C3) fractures, because of the high reported rates of poor results and complications.
Minimally invasive plating: The fracture is reduced mainly by ligamentotaxis, with further reduction and plating through limited incisions. Open medial plating disrupts the blood supply of the distal tibia more than percutaneous plating, which may predispose to delayed union or nonunion.
Evidence (Borens et al., 17 patients, low-profile medial plate): All fractures healed. Results were excellent in 47%, fair in 41% and poor in 12%. The authors recommended the technique as part of a staged protocol.
Precontoured locking plates with outriggers for proximal targeting have improved minimally invasive techniques further.
Campbell's Approach to the Fibula
Campbell does not routinely perform open reduction of the fibula at the initial stage. Length is maintained with the external fixator alone, particularly when the fibula is highly comminuted.
Alternative: Use a small anterolateral approach for articular reduction, with submuscular plate insertion and percutaneous proximal fixation, assisted by a medially based large distractor.
If the fibula needs a separate incision, make sure there is an adequate skin bridge between incisions.
With an anterolateral approach, a separate incision is sometimes needed for a percutaneous small medial plate if the fracture pattern requires it.
Fracture Morphology and Reduction Sequence
Most pilon fractures have three characteristic fragments, anterolateral, medial and posterolateral, with a central component that may be severely comminuted.
As in ankle fractures, reducing the fibula can improve reduction of the posterior fragment.
Reduction sequence in open approaches: After fibular fixation in many cases, work posterior → medial → central → anterolateral.
Technique 59.6 — Staged Minimally Invasive ORIF
Stage 1: Fibular Fixation and Spanning External Fixator
Place the patient supine on a radiolucent table with a tourniquet.
If the fibula is to be fixed, make a standard posterolateral incision.
Reduce the fibula and fix it with a one-third tubular plate.
Close the skin with 3-0 nylon sutures.
Apply a triangular external fixator spanning the ankle:
Two pins proximally in the anteromedial tibia
One threaded transfixion pin through the calcaneus
Reduce the pilon fracture provisionally using ligamentotaxis and the restored lateral column, and hold it with the fixator.
Stage 2: Definitive Fixation
Proceed with definitive reconstruction once the soft tissues allow; reappearance of skin wrinkles is the usual sign.
Position the patient supine on a radiolucent table, with a tourniquet applied.
If planning shows that percutaneous plating is not possible, reduce the articular surface through a limited anterior arthrotomy placed according to the main fracture lines. This also allows bone grafting and/or a small anterior plate.
If percutaneous plating is possible:
Estimate plate length from preoperative radiographs and check it by laying the plate on the skin under fluoroscopy.
Bend and twist the plate to fit the anteromedial distal tibia, and check the planned position on fluoroscopy.
Make one anteromedial incision at the proximal end of the planned plate position and one at the distal end.
Create an extraperiosteal tunnel between them by passing a clamp proximally or distally.
Tie a strong nonabsorbable suture (e.g., Ethibond No. 5) through the end hole of the plate. Pull the plate through the subcutaneous tunnel with a Kelly clamp under fluoroscopy. Fix it with 3.5 mm cortical or low-profile locking screws through stab incisions.
A cortical screw in the middle of the plate can be added if needed; the plate's flexibility lets it be pulled down well onto bone.
Once final images show adequate reduction and fixation, remove the external fixator.
Release the tourniquet, obtain hemostasis, and close in layers over drains.
Apply a bulky cotton dressing with a posterior plaster splint holding the ankle in neutral.
Postoperative Care
Immobilize the limb in a splint. Depending on how rigid the fixation is, discontinue the splint once the wound allows.
Then start passive and active range-of-motion exercises.
Remove sutures at 2–3 weeks.
No full weight bearing until radiographic healing is complete, usually by 12 weeks.
Technique 59.7 — Posterolateral Approach to Pilon Fractures
Rationale
The posterolateral approach (between the peroneal tendons and the FHL) was proposed as an alternative to the traditional anteromedial approach. The thicker soft-tissue cover over the plate (the FHL muscle) was expected to reduce wound and deep infection problems.
Disadvantages: Poor exposure of the ankle joint, which limits its use in fractures with anterior comminution. It has not been shown to reduce complications.
Recommended when: Articular displacement and comminution are mainly posterior, or the condition of the anterior soft tissues does not allow an anterior approach.
It is rarely used as the only approach. It is usually one part of a staged strategy, for example early fixation of the fibula and posterior fragment, followed by definitive anterior fixation of the plafond on a stable posterior column.
Steps
Under general anesthesia, remove the temporary external fixator. Give preoperative antibiotics.
Position the patient prone, exsanguinate the limb and inflate the tourniquet.
Make a posterolateral incision over the distal tibia between the peroneal tendons and the FHL, next to the Achilles tendon. Extend it proximally as needed.
Identify and protect the sural nerve.
If needed, apply a femoral distractor through new pins from the tibia to the calcaneus, to regain length or see the joint.
If needed, plate the fibula through the same incision with a 3.5 mm one-third tubular plate.
Reduce the articular fragments by direct manipulation through the fracture lines, and confirm on fluoroscopy.
Secure the articular fragments using 3.5 mm lag or 4 mm cancellous screws.
Metaphyseal fixation: C-type injuries usually need a 3.5 mm plate. B-type injuries can be treated with lower-profile plates in antiglide mode.
In C-type injuries, this approach helps restore the posterior column of the plafond, followed by a second, anterior-based approach for the remaining articular injury.
Fill large comminution defects with iliac crest graft or a suitable bone graft substitute.
Close in layers.
Fibular Plating With Definitive External Fixation
When external fixation is used as definitive treatment, fibular plating is controversial.
Potential advantages: More mechanical stability, help with reducing the anterolateral articular fragment, and restoration of tibial length and alignment.
Potential disadvantages: Longer operative time, more wound complications, and fibular malreduction that prevents accurate reduction of the plafond. It also prevents dynamization of the fixator and can lead to delayed union or varus malunion if metaphyseal defects are not grafted.
Watson et al.: In 39 failed pilon fractures treated with external fixation, 64% of failures were malunion or nonunion at the metadiaphyseal junction, in fractures with a plated or intact fibula and unrecognized tibial bone loss or comminution that was never grafted.
Prevention: Recognize tibial bone loss early and graft it before dynamizing the frame, or avoid fibular plating and hold the fibula at the mortise with a screw or wire.
There is currently no definitive evidence for or against fibular fixation in pilon fractures treated with external fixation.
Reference
Rudloff MI. Fractures of the lower extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 59, Techniques 59.6–59.7.