The tibial pilon fractures (3.77% of the total) include a group of several combinations of fractures of the tibia and fibula located at the level of the ankle junction from which, for study purposes, we separate the properly called malleolar fractures. These fractures can be very serious and very difficult to treat, to the point that some of them can only be reconstructed approximately so as to make the arthrodesis easier at a later date. All of the considerations made with regard to the fractures of the tibial plateau may be valid for the pilon fractures, with the possible aggravating circumstance of an associated fracture of the fibula (20%) at a level that is critical for the immediate stability of the assembly and for the ankle biomechanics.

Their treatment requires precise diagnosis, with X-rays and CT scan, and meticulous preoperative planning. Surgery should not begin without having the whole set of instruments and implants available. The fibula should be reconstructed first, whenever possible, through an approach that may allow manipulation of the tibial fragments adjacent to the anterior or posterior syndesmosis when necessary. The tibial approach should allow direct intra-articular observation. Since this is a predominantly cancellous bone segment, one should anticipate the use of autologous bone graft (harvested beforehand in order to avoid prolonged tourniquet times) that can be added before or after the internal fixation. Because of their complexity, it is usually necessary to perform temporary stabilizations with Kirschner wires that, when properly placed, may be useful to guide the placement of cannulated screws for definitive fixation.

Because of their inevitable subcutaneous placement, the implants of choice should be thin, like the cloverleaf plate and the tubular plates, and must be properly flattened and contoured for their perfect adaptation to the bone. We think that the spoon plates and the T plates should not be used here because of their thickness and difficult contouring. Similarly to what happens with the tibial plateau fractures, sometimes it will be necessary to use a double plate with a buttress function in order to protect the thin cortices.