Standardized Protocol: Pilon Fracture Surgery Made Simple

Learning from Dr. Li Dong's (Second Hospital of Shanxi Medical University) surgical technique for complex Pilon fractures — the "Four‑Step Foundation Method"

1. Incision — Anterolateral Approach

Dr. Li's incision starts along the anterior border of the fibula to the tip of the lateral malleolus, then curves anteriorly to the medial side of the fourth metatarsal. This provides better exposure of the anterior fracture fragments.

2. Restore and Fix the Lateral Malleolus (Fibula)

Anatomical reduction of the fibula is mandatory.

3. Use the Talus as a Template to Reduce the Tibial Plafond

Use a pointed reduction clamp or a "well" clamp (Weber‑type forceps) to pull the talus distally. The reduction criterion is that the superior edge of the lateral talar articular cartilage is flush with the superior edge of the medial cartilage of the lateral malleolus. A slight valgus position is accepted. Then, fix the talus temporarily with a 2.0‑ or 2.5‑mm K‑wire placed through the lateral malleolus. This is the "talus‑as‑template" technique.

4. Reduce the Posterior Malleolus

Two methods are described:

Method 1: Pull the anterior fragment aside, insert a small periosteal elevator through the fracture gap above the posterior malleolus, and reduce the fragment using the integrity of the posterior tibiofibular ligament. The reduction criteria are: the distal articular surface of the posterior malleolus is flush with the posterior talar articular surface, and the lateral fibular notch matches the posterior aspect of the fibula.

Method 2: Through the lateral incision, palpate the posterior malleolar fragment behind the peroneus longus and brevis muscles, push it superiorly to reduce, and then fix it from the lateral side with a 1.5‑mm K‑wire.

5. Reduce the Medial Malleolus

Make a small incision anterior to the medial malleolus, directly visualise the matching of the medial malleolar dome with the talus, and reduce. Fix temporarily with a 1.5‑mm K‑wire from anterior. Through this small incision, insert a bent reconstruction plate percutaneously to stabilise the medial malleolus.

6. Reduce the Anterior Articular Surface

Directly visualise and reduce the anterior articular fragments, then fix them temporarily with fine K‑wires from the lateral side. Finally, use an anterolateral distal tibial locking plate to secure the articular fragments. If small articular fragments cannot be held by screws or compression, consider retaining some of the fine K‑wires for additional fixation.

7. Try to Complete the Procedure Under a Single Tourniquet Time

Case Example

A middle‑aged female patient with a right Pilon fracture and associated lateral malleolar fracture after trauma.

Preoperative imaging:

Postoperative views after anterolateral approach combined with a small percutaneous medial incision: