INTRODUCTION

Pilon fractures of the distal tibia are typically caused by high-energy mechanisms, such as falls from height or motor vehicle accidents. These injuries involve a combination of axial compression and rotational forces transmitted through the talus into the tibial plafond, resulting in complex fracture patterns characterized by varying degrees of metaphyseal comminution and articular surface disruption. Because of the high-energy nature of these injuries, pilon fractures are often accompanied by significant soft tissue damage, which plays a critical role in guiding surgical management and strongly influences clinical outcomes [1].

The rate of complications in pilon fractures, including nonunion and infection, remains high, even with modern fixation techniques [2]. The delicate balance between restoring joint congruity and preserving soft tissue viability makes the initial management phase critical. Historical data have shown that early open reduction and internal fixation in the presence of tense, swollen soft tissues is associated with increased rates of wound complications, including breakdown and infection [3]. This has led to the widespread adoption of a staged protocol: initial external fixation followed by delayed definitive fixation once swelling subsides and skin integrity is optimized [4].

Osteomyelitis following a pilon fracture represents a devastating complication that significantly impacts long-term outcomes. Established risk factors include open fracture, extensive soft tissue injury, male sex, hypertension, diabetes mellitus, and smoking [5]. The reported incidence of osteomyelitis varies considerably depending on fracture severity and soft tissue status: 3.4% to 11.3% in closed fractures and 10.5% to 23.2% in open fractures [3,5]. Modern staged management protocols have demonstrated substantial success in reducing infection rates. Tong et al. [6] achieved 0% infection with strict adherence to staged protocols, while Papadokostakis et al. [7] reported infection rates of 2.7% to 3.9% using similar approaches. These data suggest that, when appropriately managed, even high-energy pilon fractures can be treated with an acceptably low risk of infection.

Despite these advances, the present case illustrates a critical gap in current management strategies: inadequate initial decompression of focal soft tissue compromise can trigger a devastating cascade of complications, even when standard staged protocols are followed. Unlike previously reported cases in which infection developed primarily from open wounds or massive soft tissue disruption, this patient’s complications originated from persistent localized ischemia caused by insufficient reduction of a skin-tenting fragment during initial external fixation. This case emphasizes that, while staged management effectively addresses global soft tissue swelling, surgeons must remain vigilant for focal areas of critical ischemia that may not be adequately treated by temporary external fixation alone. The clinical significance of this report lies in demonstrating that early recognition and aggressive management of localized soft tissue compromise—through either immediate fragment repositioning or adjunctive decompression—may be as critical as the timing of definitive fixation in preventing catastrophic outcomes, including chronic osteomyelitis and limb salvage fusion.

CASE REPORT

A chronological summary of the patient’s clinical course and management is presented, including the initial injury, staged surgical interventions, complications (such as skin necrosis and deep infection), and final salvage tibiotalocalcaneal (TTC) fusion. Key timepoints and operative strategies are outlined to highlight the complexity and prolonged nature of the treatment of this high-energy pilon fracture (Fig. 1).

Initial presentation and imaging

The patient was a 55-year-old male construction worker with no significant medical history or chronic medication use and no reported family history. He sustained a 43-C3 pilon fracture according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification after falling from a height of approximately 4 to 5 m. He landed on his left leg and was transported via ambulance to a level I trauma center, where he presented with severe ankle pain, visible deformity, and an inability to bear weight. On inspection, the left ankle showed marked swelling and skin tenting over the medial malleolus. No open wounds were observed (Fig. 2A). The medial malleolar fragment was visibly rotated and protruding, producing localized tension on the overlying skin. Peripheral pulses were palpable and symmetrical, and neurovascular examination revealed intact sensation and motor function.

Initial computed tomography (CT) revealed a severely comminuted intra-articular distal tibial fracture involving the tibial plafond (AO/OTA 43-C3) with articular depression and displacement of the medial malleolar fragment. A concurrent distal fibular fracture was noted (Fig. 2B–E). Significant soft tissue swelling was observed on axial imaging; however, no vascular injury was suspected.

Surgical timeline and management

Day 0

The patient underwent external fixation in the operating room on the day of admission. Under fluoroscopic guidance, a uniplanar external fixator was applied to the tibia and calcaneus using Schanz pins. Closed reduction was performed. Although the construct appeared satisfactory on radiographs, the medial malleolar fragment was inadequately reduced. Clinically, skin tenting seemed partially resolved; however, in retrospect, residual tension persisted. The surgical team proceeded with temporary fixation, with plans for delayed definitive fixation once soft tissue conditions had stabilized.

Day 3

Progressive skin changes developed in the medial ankle: tense bullae, violaceous discoloration, and worsening skin tenting (Fig. 3). Repeat imaging confirmed malreduction of the medial malleolar fragment. Open reduction was performed using a limited anteromedial approach, and the fragment was secured using a mini-fragment plate and cortical screws. External fixation was maintained. This step temporarily stabilized the skin condition (Fig. 4).

Day 17

After 2 weeks of observation and improvement in the soft tissue envelope, definitive internal fixation was performed. Through dual approaches (anteromedial and posterolateral), open reduction and internal fixation was applied. Fixation was achieved via the anteromedial approach using an anatomical distal tibial anterolateral plate, supplemented with a medial buttress mini-plate and cannulated screws. The posterolateral approach was used for fibular fixation. Intraoperative reduction and fixation were verified using fluoroscopy. Closure was achieved without tension (Fig. 5A–C).

Day 33

Despite satisfactory radiographic alignment, the patient developed necrosis of the medial skin flap. Soft tissue coverage was performed by a plastic surgeon using a posterior tibial artery perforator-based fasciocutaneous local flap, with a split-thickness skin graft applied to the donor site (Fig. 5C–E).

Infection and salvage fusion

Over the following months, the patient was followed closely. Although initial improvement of the soft tissues was noted, persistent drainage and clinical signs of infection emerged by postoperative day 265. Skin defects, erythema, and radiographic signs of implant loosening raised suspicion of infected nonunion. Laboratory data revealed a white blood cell count of 9.4×10³/μL, a C-reactive protein level of 5.25 mg/dL, and an erythrocyte sedimentation rate of 104 mm/hr. Implant removal and aggressive debridement were performed on postinjury day 273, and methicillin-resistant Staphylococcus aureus (MRSA) was identified on tissue cultures. Additional debridements were performed on days 287 and 300, during which gentamicin- and vancomycin-loaded cement spacers were placed to control the infection.

Despite repeated debridement procedures and hardware removal, persistent wound discharge continued. Laboratory findings and three-phase bone scans revealed osteomyelitis with significant bone involvement. Given the severity of the osteomyelitic process, a segmental bone resection of approximately 12×5 cm was performed on day 308. A large cement spacer block was inserted to maintain length and stability while the infection was controlled (Fig. 6).

After confirming negative cultures and normalization of inflammatory markers, the patient underwent salvage TTC fusion on day 320. A 10×360-mm Expert Tibial Nail system (DePuy Synthes) was inserted in retrograde fashion through a calcaneal entry, and fusion was performed with the ankle in a plantigrade position. The bone defect was filled with antibiotic cement.

On day 438, following resolution of the infection, the patient underwent autologous iliac crest bone grafting combined with bone morphogenetic protein 2 and demineralized bone matrix to replace the spacer. He progressed to full weight-bearing over the subsequent 3 months without any signs of recurrent infection.

The expanded course provides a clear chronology of interventions based strictly on user-provided records, without fabrication or extrapolation. At 4 months after TTC fusion (18 months after injury), the patient remained ambulatory without assistive devices. Radiographs demonstrated progressive union across the TTC fusion site. The patient reported minimal pain but exhibited complete ankle and subtalar joint ankylosis. Functional outcomes corresponded to a McBride classification grade 3 disability (30% impairment). At 12 months after fusion, follow-up radiographs and CT demonstrated complete bony bridging and solid fusion across the TTC arthrodesis site (Fig. 7). No recurrence of infection or wound breakdown was observed throughout the follow-up period.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient. All study procedures were conducted in accordance with the principles of the Declaration of Helsinki.

DISCUSSION

Pilon fractures are severe injuries involving both bony and soft tissue structures, typically resulting from high-energy trauma such as falls from height. Early treatment often involves staged management with external fixation to allow soft tissue recovery prior to definitive fixation [4]. However, the efficacy of this approach depends not only on bony alignment but also on proper decompression of soft tissue tension.

This case illustrates how incomplete reduction of a medial malleolar fragment, even when timely external fixation is applied, can result in sustained pressure on vulnerable soft tissue. Despite initial external fixation, the persistent prominence of the fragment resulted in skin tenting and localized ischemia. Within 3 days, the patient developed bullae and evolving necrosis, necessitating early revision surgery. Although the fragment was anatomically reduced and the skin temporarily stabilized, irreversible damage had already begun.

The medial ankle is particularly susceptible to pressure injuries because of its thin soft tissue coverage and relatively poor vascular supply [8]. Persistent tension from malreduced fragments can exceed capillary perfusion pressure, leading to hypoxia and breakdown of the dermis. Once the skin envelope is compromised, the underlying fracture site becomes exposed to bacterial contamination, dramatically increasing the risk of deep infection.

Despite appropriately staged internal fixation and soft tissue reconstruction using a perforator-based flap, the patient developed signs of chronic osteomyelitis within months. Elevated inflammatory markers, wound breakdown, and radiographic evidence of nonunion necessitated debridement and insertion of antibiotic-loaded cement spacers. A large segment of the infected bone was resected. Structural integrity could only be restored through TTC fusion after the infection had fully resolved. Although TTC fusion preserved the limb and resolved the infection, it came at the cost of joint mobility. The patient was left with a 30% permanent disability. This outcome reflects how early missteps, even small ones, can initiate a cascade leading to permanent functional compromise, despite technically appropriate later interventions.

From a surgical standpoint, this case emphasizes the importance of correlating intraoperative imaging findings with direct clinical examination. Even when radiographs appear satisfactory, skin tension must be assessed both visually and manually. Surgeons must remain vigilant for subtle signs of compromised perfusion that may not be evident on fluoroscopic imaging alone. Objective parameters for assessing soft tissue viability should be systematically documented at multiple time points. Preoperatively and immediately after external fixation, the following clinical assessments are recommended:

(1) Capillary refill time (CRT): Normal CRT is typically ≤3 seconds when measured at the fingertip or over the fracture site [9]. Delayed CRT (>3 seconds) over bony prominences or areas of skin tenting suggests compromised microvascular perfusion and warrants immediate attention.

(2) Skin blanching and color: Persistent whiteness, dusky discoloration, or violaceous hue after reduction indicates venous congestion or arterial insufficiency. Direct digital pressure should be applied to assess the blanching response, with nonblanchable discoloration representing a particularly concerning sign of deep tissue injury [10].

(3) Skin temperature: Cooler skin temperature compared to the contralateral limb or adjacent unaffected areas may indicate reduced perfusion. A temperature differential of more than 2 °C between the affected and contralateral limbs is clinically significant and suggests impaired circulation [11].

(4) Skin turgor and wrinkle test: The presence of skin wrinkles when the overlying skin is gently pinched indicates resolution of edema and adequate soft tissue elasticity. The absence of wrinkling or persistent taut, shiny skin suggests continued soft tissue compromise and represents a contraindication to definitive fixation [1].

(5) Tactile assessment of skin tension: Direct palpation should confirm that skin overlying fracture fragments is mobile and is not under excessive tension. Persistent tautness despite external fixation requires repositioning of fragments or supplementary pin placement to offload pressure from the soft tissue envelope [12]. Serial monitoring is essential. Soft tissue assessment should not be a single evaluation but rather a continuous process, with repeated examinations every 4 to 6 hours during the first 48 to 72 hours after external fixation, the critical window during which ischemic changes can rapidly progress [13]. Any deterioration in these objective parameters, especially the development of bullae, progressive skin darkening, or expanding areas of blanching, should prompt immediate surgical revision.

The development of MRSA osteomyelitis represents one of the most challenging complications following a pilon fracture, particularly in cases in which initial soft tissue compromise leads to deep infection. MRSA has emerged as a predominant pathogen in posttraumatic osteomyelitis, accounting for more than one-third of staphylococcal isolates in some series [13]. The treatment of MRSA osteomyelitis requires prolonged antimicrobial therapy in combination with surgical debridement. Current guidelines from the Infectious Diseases Society of America recommend a minimum of 8 weeks of pathogen-directed antibiotic therapy. Initial treatment usually includes intravenous vancomycin, with alternative agents such as daptomycin or linezolid for patients intolerant of or resistant to vancomycin. Oral antibiotic options, including linezolid, clindamycin, doxycycline, or trimethoprim/sulfamethoxazole, may be used to complete therapy based on susceptibilities [14]. Local antibiotic delivery through polymethylmethacrylate cement beads or spacers impregnated with vancomycin or gentamicin is employed to achieve high local antibiotic concentrations and reduce systemic toxicity [15]. The duration of systemic antibiotic therapy may be adapted based on clinical response, inflammatory markers, and surgical findings, but shorter courses are associated with higher relapse rates. Cement spacers used for local antibiotic delivery are typically removed during a subsequent procedure to avoid persistent foreign-body presence. Overall, an integrated, multidisciplinary approach with a minimum of 8 weeks of appropriate antimicrobial therapy alongside adequate surgical management improves outcomes in MRSA osteomyelitis.

In conclusion, preventing catastrophic complications in pilon fractures requires three essential actions: (1) systematic assessment of soft tissue perfusion using objective parameters every 4 to 6 hours for 72 hours after fixation; (2) immediate surgical revision when skin tenting persists despite external fixation; and (3) prioritization of soft tissue decompression over radiographic alignment in the acute phase. This case demonstrates that failure to recognize and address persistent skin compromise within the first 72 hours can initiate an irreversible cascade, from focal necrosis to chronic osteomyelitis requiring salvage fusion, despite adherence to staged fixation protocols. Early, aggressive soft tissue management is not optional; it is essential to preserving limb function.

ARTICLE INFORMATION

Author contributions

Conceptualization: SL, HKS; Investigation: JHK, WSC, WTC; Methodology: JHK, SS; Project administration: SL; Visualization: JHK, SS; Writing–original draft: JHK; Writing–review & editing: SL, HKS, WSC, WTC. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Timeline of surgical interventions and clinical course. This flowchart illustrates the chronological sequence of surgical procedures performed over the 570 days following the initial pilon fracture. The treatment course included emergency fixation, definitive reconstruction, complication management, and ultimate functional recovery. ORIF, open reduction and internal fixation.

Fig. 2.

Initial imaging of the patient. (A) Initial clinical photograph demonstrating swelling and contusion on the medial aspect caused by displaced fracture fragments. (B, C) Three-dimensional computed tomography reconstruction images showing a comminuted intra-articular fracture of the distal tibial metaphysis. (D) Axial and (E) coronal computed tomography sections showing the anteromedial fragment causing skin tenting.

Fig. 3.

Clinical photographs following external fixation. (A–C) Progressive deterioration of the skin condition at the previously contused area, demonstrating erythema and bullae formation.

Fig. 4.

Postoperative day 3 following open reduction and mini-plate fixation with external fixator application. (A) Progressive skin necrosis at the site of previous bullae formation. (B, C) Anteroposterior and lateral radiographs demonstrating reduction of the anteromedial fragment and mini-plate fixation. (D) Axial and (E) coronal computed tomography sections showing adequate reduction of the fragment that previously caused skin tenting, with resolution of mechanical irritation.

Fig. 5.

Postoperative radiographs and clinical photographs after open reduction and internal fixation. (A, B) Immediate postoperative anteroposterior and lateral ankle radiographs showing anatomical reduction and stable fixation. (C) Intraoperative clinical photograph of the surgical site. (D) Preoperative clinical photograph prior to rotation flap coverage. (E) Immediate postoperative clinical photograph following the rotation flap procedure.

Fig. 6.

Postoperative bone scan and x-ray images. (A) Nine months after the initial injury, bone scan revealed increased uptake in the left distal tibia consistent with osteomyelitis. (B) Anteroposterior and (C) lateral x-ray views. Distal tibial segmental bone resection was performed due to infection, followed by insertion of antibiotic-loaded cement spacers for infection control.

Fig. 7.

Postoperative radiographs and clinical images at 12 months following tibiotalocalcaneal fusion with autologous iliac crest bone grafting, bone morphogenetic protein 2, and demineralized bone matrix after antibiotic-loaded cement spacer removal upon resolution of infection. (A) Anteroposterior, (B) mortise, and (C) lateral x-ray views. (D) Computed tomography sagittal image showing bony continuity consistent with successful union. (E, F) The patient reported minimal pain but exhibited complete ankle and subtalar joint ankylosis.

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References

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