Life After Pilon Fracture: Recovery Time & Prognosis

What is the tibial plafond (= pilon of the tibia)?

The tibial plafond (= pilon of the tibia) is a large bony protrusion of the tibia, located at the lower end.

It partly forms the ankle joint: it is on this bony part that the two ankle malleoli are located:

• the inner malleolus;
• the outer malleolus.

The tibial plafond articulates with a bone in the foot, the talus, to form the ankle joint.

What does a tibial plafond fracture look like? Definition

The tibial plafond can break on its own or simultaneously with other parts of the tibia, fibula (formerly known as the peroneal bone), and foot.

Other anatomical structures may be affected (muscles, nerves, blood vessels, etc.).

A tri-malleolar fracture is mentioned when both malleoli are broken in addition to the tibial plafond.

And a complex ankle fracture occurs when the tibial plafond, both malleoli, and the fibula are broken.

3 to 10% of tibia fractures are tibial plafond fractures. In 75 to 90% of cases, the fibula is also affected, making it a tibia-fibula double fracture.

These fractures often occur due to:

• falls or jumps from a great height;
• road accidents.

Only an X-ray (and sometimes a CT scan, MRI, or tomography) can precisely determine which part of the bone is broken and how.

The anterior part (front) of the tibial plafond. The posterior part (back) of the tibial plafond. These fractures can be:

• open: the tibia bone is exposed outside the skin; about 1/4 of tibial plafond fractures are open;
• with or without displacement: the gap between the broken bone fragments varies. Closed and non-displaced tibial plafond fractures generally recover faster.

There are also classifications used by orthopedic surgeons. However, none are widely accepted, and they do not change the general lines of rehabilitation and recovery.

Source: Mair 2021

What is the treatment for a tibial plafond fracture?

There are two main types of treatment for a tibial plafond fracture.

It is generally an orthopedic surgeon who determines which treatment to pursue based on the type of fracture and the person’s overall condition (before and after the accident):

• surgical treatment: an operation is performed, and hardware is implanted;
• conservative treatment (rarer): no operation, and immobilization is often necessary.

And in all cases:

• antibiotics (to prevent infection) and analgesics (pain relief) are often given, in addition to treatment against the risk of thrombosis;
• physical therapy sessions are often prescribed. Sometimes, a stay in a rehabilitation center is suitable.

Tibial plafond surgery: when and why?

Even when necessary, the surgery does not necessarily take place immediately after the fracture.

The team taking care of you may sometimes apply traction when the soft tissues do not seem to be in good enough condition for immediate surgical intervention.

Other teams may operate right away (within 72 hours after the accident), especially to limit the risk of infection.

During the operation, hardware is put in place to stabilize the fracture, realign, and hold the various bone fragments.

• Osteosynthesis with one or more plates and screws
• With an external fixator
• More rarely, arthrodesis, which prevents movement in the joint.

If the fracture is open, skin flaps from another location are sometimes used to cover the injured area. This is done simultaneously with the operation to reduce and stabilize the fracture or at a later time. The hardware is sometimes kept for life if it does not cause any issues or removed in the months or years following. Once the consolidation is well established.

When the loss of soft tissue is too significant or the wound contamination is too severe, radical debridement, washing, treatment with a vacuum-assisted closure (VAC) device, and temporary external fixation may be necessary. Along with intravenous antibiotic therapy.

By reading the operation report (often sent to your general practitioner and physiotherapist), you will learn more about the specific type of operation you underwent.

Source : Bear 2018 ; Mair 2021

Conservative treatment: What is it?

Reducing and fixing the fracture with surgery is the preferred treatment for tibial plafond fractures.

In some people (especially the elderly), surgery may sometimes not be safely performed. In such cases:

• the fracture is reduced without surgery;
• immobilization with a cast (most often) or walking boot (rare) is prescribed;
• it is recommended not to put weight on the fractured leg while walking for 6 to 10 weeks.

Source: Mair 2021

What does the rehabilitation of a tibial plafond fracture involve?

Some people go to a rehabilitation center or follow-up and adaptation care after this type of fracture.

Others return home after a few days in the hospital.

In this case, physiotherapy sessions are often prescribed:

• either upon leaving the hospital;
• or at the time of the follow-up X-ray, a few weeks after the accident when more movement is possible.

Rehabilitation during the consolidation phase

During the first weeks after a tibial plafond fracture, the main goal is for the fractured bones to consolidate. There is no rehabilitation technique (or medication) that can accelerate this.

The goal of rehabilitation during this phase is to prevent too much loss of muscle and functional capabilities.

It is important to ensure that the ankle and knee do not stiffen if there is no cast or contraindication to mobilization. Remaining as active as possible, without necessarily attempting specific exercises, is one of the best ways to prevent stiffness and loss of strength.

The second goal of rehabilitation during the early weeks is to alleviate painful symptoms and potential edema associated with the fracture by providing various advice.

Rehabilitation once healed

The second phase of rehabilitation begins when consolidation is achieved or well underway. This can be objectively assessed after a radiographic check performed approximately 6-10 weeks after the diagnosis of the tibial plafond fracture, whether or not it has been operated on.

The main objective of this phase is to regain perfectly functional and pain-free use of the operated lower limb. First for:

• walking and other weight-bearing activities of the lower limb (prolonged standing, transfers),
• then for sports activities.

Rehabilitation generally begins with a gradual reintroduction of weight-bearing on the lower limb that has been non-weight-bearing for several weeks. This can be done by visual observation or with the help of a balance.

The patient’s pain is the main indicator. The tolerated weight on the ankle should be gradually increased, day by day or week by week.

Walking initially involves using two crutches in a three-step pattern, then alternately, and finally with a single crutch before complete withdrawal. Walking without crutches is possible at best 1 or 2 months after a tibial plafond fracture, and most often 3 to 4 months later.

Are there specific rehabilitation techniques that work better than others? No.

For example, people whose ankles are passively and manually mobilized do not recover better or faster than those who simply perform exercises or supervised walking. The same applies to stretching: it is not essential and does not bring significant improvement.

Similarly, the use of electrotherapy, ultrasound machine, TENS therapy, or shockwave therapy does not provide additional benefits. (Cochrane 2012)

What matters is that the person gradually puts weight on their lower limb and moves their ankle and knee without exacerbating pain. It doesn’t matter the specific situations (active, passive, supervised, autonomous) created to achieve this.

Is it normal to experience pain after a tibial plafond fracture?

Whether you have undergone surgery or had a cast for a tibial plafond fracture, it is common to experience pain, even when taking painkillers. These pains can be significant in the first days following the fracture but decrease in intensity over the following days or weeks.

The intensity of the pain is not necessarily related to the severity of the fracture. In other words, if you are in a lot of pain, it does not mean you have a very serious fracture that you should worry about.

Pains can persist for several weeks even at rest, without putting weight on the leg. This is not inherently worrisome, especially if they do not interfere with sleep or daily activities.

These pains often result from inflammation, a beneficial defense reaction of our body.

Due to the fracture (and the surgery when it was necessary), tissues need to heal to become operational again.

When a tissue in the body is injured, immune cells such as macrophages and lymphocytes:

• are recruited to the affected area;
• then release chemicals to protect and heal the damaged tissue.

In doing their job, these cells can cause vasodilation.

This is an increase in the diameter of blood vessels, allowing the cells to arrive more quickly in the injured area.

These reactions can incidentally cause undesirable (but not serious) effects such as:

• pain; redness;
• warmth;
• swelling,
• edema.

Why does the ankle often swell after a pilon fracture?

The ankle and calf systematically swell after a tibial plafond fracture, and even after an ankle sprain, which is nevertheless a less severe trauma. This is a normal reaction of the body, related to inflammation, like pain.

This swelling (or edema) lasts at least several weeks, and often several months. It is not uncommon for edema to persist several years after breaking the tibial plafond.

This is often a source of concern and consultation for patients. However, it is not inherently worrisome. If the edema is not associated with significant pain or discomfort in performing certain activities, there is nothing specific to be done.

Compression socks or stockings can be worn to limit edema, in addition to their preventive effect on the risk of phlebitis.

What is the healing & recovery time for a tibial plafond fracture?

It takes at least 2 months for the healing to be well advanced. Often more for fractures affecting the joint.

A follow-up X-ray will determine whether the healing is progressing well or not.

Even if the bone is not completely healed, it is still possible to gradually reintroduce movements and even support.

Your physical therapist or your doctor or surgeon will be able to tell you what is appropriate or not in your case in case of delayed healing.

Walking after a pilon fracture: when is it possible?

It is possible to resume walking in the first few days after the emergency room visit or hospitalization, but of course, adapting the way of walking:

• without support or with contact support (putting a maximum of 10/15 kg on the leg), leaning on crutches or a walker;
• with partial or total support on the fractured leg, depending on the pain. But always with crutches or a walker for a few weeks to unload a little and stabilize the gait.

How do you know if you are allowed to support or not? It is written in your discharge letter or operation report. A copy is normally included in your discharge file and sent to the treating physician and physiotherapist.

Some people with an external fixator can still walk by leaning on the operated leg (Mair 2021).

Walking “as before” is usually regained after several months, gradually.

See how to walk with a broken leg or foot.

What are the possible complications and sequelae of a tibial plafond fracture?

In the 1990s (and before), the complication rate after a tibial plafond fracture was very high. But this has evolved significantly.

This table outlines the complication rate of surgically treated tibial plafond fractures. I will explain it afterward.

For the most severe fractures (the less severe ones are probably less included in studies):

• an infection, occurring in 1 in 10 to 1 in 5 people, usually in the early days or weeks; delays or lack of consolidation in 2 to 6% of cases;
• the need for additional surgery; post-traumatic arthritis (in 10 to 44% of cases);
• residual pain (2 out of 3 people);
• patients feeling a loss of flexibility and ankle function (3 out of 4 people).

Source: Mair 2021

What is the healing time after a tibial plafond fracture?

We do not have studies that precisely follow the healing and recovery time of different individuals after a tibial plafond fracture. Therefore, I relied solely on my professional experience to provide some approximate durations.

Stage	Typical Timeframe
Bone consolidation	6-10 weeks or more
Reduction of swelling	Several months
Resumption of walking with crutches, non-weight-bearing or with assisted support	Immediate
Resumption of walking with weight-bearing	Sometimes immediate, sometimes weeks or months
Return to work	2 months – several years (57% returned at 12 months)
Return to sports	3-12 months
Full functional and muscular recovery	6 months – 2 years