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Pilon fracture

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Updated Sep 2026
Illustration: ankle

What you're feeling

A pilon fracture is a break in the bottom end of your shin bone, right where it forms the ankle joint. The pain sits deep in your ankle and lower leg, and it usually hurts on both sides of the joint, not just one spot. Because the joint surface itself is involved, the ache tends to spread across the whole ankle rather than staying in one place.

The pain is usually worse when you're on your feet. Standing, walking, and pushing off that foot all load the injured joint, so expect the ache to build through a day of activity. Swelling around the ankle is common, and it can make the skin feel tight and tender. Resting with the foot up often settles things down. Many people find the ankle is stiff and sore on waking, then loosens a little as they move around.

Everyday tasks that need a stable, pain-free ankle become hard. Walking to the letterbox, standing at the kitchen bench to cook, climbing stairs, and getting to the bathroom without support can all be a struggle. Driving may be off the table for a while if it's your right ankle. Even getting shoes on can be tricky when the ankle is swollen and stiff.

This injury can also wear you down in ways that aren't just physical. Pain that limits your daily life for months, and trouble sleeping because of the ankle, can affect your mood and overall wellbeing. That's a normal response to a serious injury, and it's worth mentioning to your care team if it's happening to you.

One more thing to know: this is an injury where the details matter. The way the broken bone pieces sit after treatment has a real bearing on how the ankle works later, and surgeons plan carefully around the soft tissue and swelling before operating. Your surgeon will talk you through the plan for your particular fracture.

What's actually happening

Your ankle is a snug socket formed by three bones: the shin bone on top, and two smaller bones either side that grip it like a clamp. The end of the shin bone that forms the roof of that socket is called the plafond. In a pilon fracture, that roof breaks. The force usually comes straight down through the foot, such as in a fall from height or a car crash, and the ankle bone (talus) drives up into the shin like a hammer driving a nail into a piece of wood. The joint surface shatters into pieces.

The damage is not just bone. The socket is lined with smooth cartilage, the slippery surface that lets the joint glide. When the break runs through that surface, the pieces can sit unevenly, and the ankle loses its smooth track. That is why the swelling, the deep ache, and the trouble bearing weight you have just read about happen: the joint itself is injured, not just the bone around it.

The ankle also has strong straps of tissue holding the bones together, including one on the inner side that keeps the joint from splaying apart. A hard downward force can strain or tear these too. Surgeons check several things before calling an ankle lined up again: the two side bones must be back to their full length, the ankle bone (talus) must sit square in the socket with no tilt, the gap on the inner side must be back to its normal width, and the two leg bones must not be pulled apart.

Swelling matters here too. It can be severe, and surgery often waits 5 to 14 days for it to settle enough that the skin can be closed safely afterwards. Rushing in through swollen, blistered skin raises the risk of wound trouble, so the delay is a planned part of treatment, not a hold-up.

What we can do about it

The first step is often a temporary external frame. This is a scaffold outside your leg that holds the bone steady while the swelling settles. It protects the damaged soft tissue, the skin and muscle around the break, and it buys time before any operation on the bone itself. Waiting 5 to 14 days for swelling to go down is a planned part of treatment, not a hold-up.

Scans shape the plan. A CT scan builds a detailed picture of the broken pieces, and planning the operation on those images helps put the joint surface back together and lowers the chance of wound trouble. Once the skin is ready, the usual operation is open reduction and internal fixation. In plain terms, we open the ankle, rebuild the shattered joint surface, and hold the pieces with a plate and screws. The approach we use depends on where your particular fracture sits, and some patterns are reached through incisions at the back or inner side of the ankle.

For fractures where the bone is broken into too many pieces to rebuild, or where the soft tissue will not safely allow plates, there are other options. An external frame can be the main treatment rather than a temporary one. For a small group of severe injuries, fusing the ankle, joining the shin bone to the ankle bone (talus) in one solid block, may be the choice. A rod through the heel into the shin is another option for some patients, and it can allow weight on the foot soon after surgery.

Open fractures, where bone breaks through the skin, need extra care. We clean the wound thoroughly, use antibiotics, and often start with an external frame before moving to the next stage. Early movement exercises after surgery help the ankle recover and reduce complications, and we will guide you through those when the time comes.

What to expect

A pilon fracture is a serious injury, and it is honest to say the road can be long. More than three years after the injury, some people still feel the effects on their health and wellbeing. How you fare depends a lot on how badly the bone and soft tissue were damaged in the first place, and on how well the joint surface is put back together. More severe injuries tend to have a poorer outcome.

This injury affects quality of life regardless of which treatment is used, because the injury itself is severe. That is not a reason to lose heart, but it is worth knowing upfront. The things that matter most are careful planning before surgery, careful technique, and giving the swelling time to settle before operating. When the joint surface is rebuilt well, the ankle has a fair chance of serving you well. When the pieces sit unevenly, the ankle tends to pay for it later.

There are real risks to be aware of. Deep infection needing more surgery happens in a small number of cases, around 6% when the bone is fixed early in suitable patients. Wound problems are the complication this injury is known for, which is why your surgeon plans carefully and often waits for swelling to settle. Some people develop arthritis in the ankle over time, and the hardware holding the bone can occasionally break or loosen. If you have other health conditions, such as diabetes or problems with the nerves in your feet, healing can be slower and results less predictable.

Leaving a displaced pilon fracture alone is not a good option. The joint surface stays in pieces, and the ankle wears out faster as a result. Managed well, most people get back to daily life, though some are left with stiffness, an ache in cold weather, or a joint that will never feel quite like it did before. Your care team will keep an eye on you for at least a year, because infections most often show up in that window. Ask questions at any point. Knowing what lies ahead makes the months easier to walk through.

When to see someone

A pilon fracture is an emergency. Go to an emergency department if you have had a fall from height or another heavy impact and your ankle is severely painful, swollen, or you cannot put weight on it. The same applies if the bone has broken through the skin, or if the skin is stretched tight and blistered over a badly swollen ankle. These injuries need assessment straight away, not a GP appointment.

After treatment, see your GP promptly if you notice spreading redness, warmth, or oozing from a wound, or if you develop a fever. Deep infection is a known risk with this injury, and it most often shows up within the first year. Ask for a specialist review if pain and swelling are not settling as expected, or if your ankle is not improving over the months after surgery.

Reviewed by AI synthesis (v2) — pending human review · 9 September 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

Bony Anatomy

  • The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus [3].
  • The ankle mortise articulates with the dome of the talar body [3].
  • The talar dome is wider anteriorly and narrower posteriorly [3].
  • The ankle mortise widens 1 to 1.5 mm during motion from plantar flexion to dorsiflexion [3].
  • Medial and superior clear spaces appear wider with the foot in plantar flexion [3].
  • The distal fibula has a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [3].
  • The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [3].
  • Ankle dorsiflexion results in external rotation and proximal translation of the fibula [3].
  • The primary functions of the foot and ankle are to provide weight-bearing support and forward ambulation [3].

Ligamentous Anatomy

  • The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [3].
  • The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [3].
  • The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [3].
  • The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [3].
  • The ATFL is the weakest ankle ligament [3].
  • The PTFL is the strongest ankle ligament [3].
  • The distal tibiofibular joint (ankle syndesmosis) and fibula provide stability against lateral talar translation [3].
  • The deltoid ligament complex is the primary ankle stabilizer during stance [3].
  • The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body [3].
  • The deep deltoid ligament functions primarily to resist lateral talar translation and external rotation [3].
  • The posterior deep deltoid is the most important component of the deep deltoid ligament [3].
  • The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [3].
  • The superficial deltoid ligament functions primarily to resist valgus and eversion ankle forces [3].
  • The deltoid ligament consists of superficial and deep layers, with at most six bands, of which only the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament are constant [8].
  • The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [8].
  • The deep portion of the deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [8].
  • The anterior and posterior deep tibiotalar ligaments are intra-articular but extrasynovial [8].
  • The deep posterior band comprises the largest band of the deltoid complex [8].
  • The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [8].
  • The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [8].
  • The dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [8].
  • Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid ligaments [8].

Biomechanics & Motion

  • The ankle joint is responsible for most sagittal plane motion of the foot and ankle [3].
  • The range of motion for plantar flexion is 23 to 48 degrees [3].
  • The range of motion for dorsiflexion is 10 to 23 degrees [3].
  • The ankle joint also contributes to inversion, eversion, and rotation [3].
  • A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral [3].
  • A simplified model of the ankle joint has a coronal axis from superomedial directed distally and laterally to the tip of the fibula [3].

Pathophysiology & Injury Patterns

  • More than 75% of ankle ligament injuries involve the lateral ligament complex, particularly the ATFL and CFL [9].
  • Medial ligament injuries are usually seen in association with a fracture or joint injury [9].
  • Isolated rupture of the deltoid ligament without lateral ligamentous or fibular injury is rare [8].
  • Syndesmotic injury, lateral ligamentous injury, and fibular fractures are common associated injuries with deltoid ligament injury [8].
  • The Danis–Weber Type A classification describes a transverse fracture of the fibula below the tibiofibular syndesmosis, sometimes associated with an oblique or vertical fracture of the medial malleolus [7].
  • The Danis–Weber Type B classification describes an oblique fracture of the fibula at the level of the syndesmosis, often accompanied by an avulsion injury on the medial side [7].
  • The Danis–Weber Type C classification describes a fracture above the level of the syndesmosis, meaning the tibiofibular ligament and part of the interosseous membrane must have been torn [7].
  • To achieve a reduced ankle, the fibula must be restored to its full length [7].
  • To achieve a reduced ankle, the talus must sit squarely in the mortise with no tilt [7].
  • To achieve a reduced ankle, the medial joint space must be restored to its normal width [7].
  • To achieve a reduced ankle, there must be no tibiofibular diastasis [7].
  • Syndesmotic malreduction risk is associated with incisura anatomy, where deep incisuras with the fibula not engaged are at risk of overcompression [11].
  • Anteverted incisuras are at risk of anterior fibular translation in syndesmotic malreduction [11].
  • Retroverted incisuras are at risk of posterior fibular translation in syndesmotic malreduction [11].
  • Fixation of a syndesmotic injury with a single suture-button construct did not restore physiological fibular motion [11].

Investigations

Osteochondral Lesions

  • Osteochondral lesions are seen in up to 70% of ankle sprains and 75% of ankle fractures [12, 13].
  • The most common location for osteochondral lesions is the medial talar dome [12, 13].
  • Modern data indicate that the most common location for medial talar dome lesions is central, contradicting historical beliefs that posterior locations were more common [12, 13].
  • Medial talar dome lesions are larger and deeper than lateral lesions [12, 13].
  • Lateral talar dome lesions are less common than medial lesions [12, 13].
  • Lateral talar dome lesions are more often unstable, displaced, or symptomatic than medial lesions [12, 13].
  • Lateral talar dome lesions are often refractory to conservative measures [12, 13].
  • AP, mortise, and lateral weight-bearing ankle x-rays may not demonstrate subtle osteochondral lesions [12, 13].
  • CT scans are helpful for determining the integrity of subchondral bone and identifying cysts in osteochondral lesions [12, 13].
  • MRI is sensitive for all osteochondral lesions but the edema pattern frequently overestimates the severity of the injury [12, 13].
  • Linear fluid signal deep to subchondral bone on MRI indicates an unstable osteochondral injury [12, 13].
  • MRI has a sensitivity of 92% for predicting stable versus unstable osteochondral lesions [12, 13].

Ankle Fractures and Syndesmosis

  • MRI lacks additional diagnostic value for stability assessment of the ankle mortise in supination-external rotation-type ankle fractures [16].
  • Preoperative computed tomography scans play a role in operative planning for malleolar ankle fractures [16].
  • Malreduction of the posterior malleolus is significantly more likely to lead to malreduction of the syndesmosis [16].
  • Ultrasonographic examination can be used to evaluate the deltoid ligament in bimalleolar equivalent fractures [16].

General Imaging Principles

  • Advanced imaging is often helpful in diagnosis when combined with a thorough clinical examination for foot and ankle injuries [15].
  • MRI is used for the evaluation of anterolateral soft tissue impingement of the ankle [1, 17].
  • MRI is used for the evaluation of osteochondral lesions of the talus [1].
  • MRI is used for the pre-operative evaluation of the anterior talofibular ligament in chronic ankle instability [1].
  • MRI is used for the diagnosis of plantar plate injury with reference to intraoperative findings [1].
  • MRI is used for the evaluation of traumatic ligamentous injuries of the ankle and foot [1].
  • CT and MR imaging are used for the evaluation of the postoperative ankle and foot [1].
  • MRI is used for the evaluation of peroneal tendon abnormalities in routine foot and ankle imaging [14].
  • MR imaging is used for the evaluation of entrapment neuropathies of the lower extremity, including the ankle and foot [18].

References

[1] Campbell S Operative Orthopaedics 4 Volume Set. REFERENCES > FOOT AND ANKLE.

[3] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > BIOMECHANICS OF THE FOOT AND ANKLE.

[7] Apley And Solomon S Concise System Of Orthopaedics And Trauma. Treatment.

[8] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Ankle Sprains > Medial Ankle Injury.

[9] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INJURIES OF THE ANKLE.

[11] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Foot and Ankle Anatomy and Biomechanics > Annotated References.

[12] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > OSTEOCHONDRAL LESIONS.

[13] Miller S Review Of Orthopaedics. OSTEOCHONDRAL LESIONS.

[14] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > PERONEAL TENDONS.

[15] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Summary.

[16] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Annotated References.

[17] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > IMPINGEMENT.

[18] Campbell S Operative Orthopaedics 4 Volume Set. COMBINED HAMMER TOE AND MALLET TOE DEFORMITY WITH ASSOCIATED DOUBLE CORNS > REFERENCES > TARSAL TUNNEL SYNDROME.

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