Our son was in a snowboarding accident and smashed into a tree foot first. The ankle shattered into many pieces. Both bones in the lower leg were broken. From the X-ray, it’s clear that nothing in the ankle is lining up properly. The foot is swollen with open wounds and bones sticking out. Yet they are delaying surgery and we can’t figure out why. Shouldn’t they be getting in there and patching things back together?

What you have just described sounds like what we would call a pilon ankle fracture. The term pilon fracture (also known as a hammer) fracture occurs when one bone is driven into another bone with force. The bone may be broken into more than one piece. This is a comminuted pilon fracture. Pilon fractures can affect the spine and either bone in the lower leg (tibia or fibula).

The most common pilon fracture affects the lower end of the tibia. The break occurs across the entire bone and into the ankle joint. It results from a high-energy, loading injury from the foot up into the bone. Car accidents, skiing injuries, and falls during horseback riding are the most commonly reported cause of pilon fracture.

Surgery is needed but the timing of the procedure can be extremely important in saving the foot. Making incisions into swollen, infected, and/or damaged soft tissues can set off a chain of events that result in very poor outcomes. Amputation from nonunion of the fractures and deep infection are two potential serious complications. Surgeons have learned that a wait-and-see approach might be best.

Unless the surgeon is able to bring the joint surfaces back together and match them up evenly, the risk of joint arthritis is much greater. Likewise, if the alignment of the ankle joint isn’t normal, there may be a loss of stability, uneven wear, inability to walk without a limp, and early development of osteoarthritis. Some experts in this area recommend the following:

  • All bruising over the surgical site should be gone before cutting the leg open.
  • Fracture blisters and open fracture wounds should be healed without infection.
  • Swelling should go down enough to create a positive skin wrinkle test (skin wrinkles form at the front of the ankle when the patient moves the foot toward the face).
  • The typical waiting time from injury to surgery is between 10 days and three weeks.

    Don’t hesitate to ask if you have concerns or questions about the type of treatment and/or the timing of surgery. A parent’s worry is always important. As the patient’s closest support system, you need to be satisfied that everything possible from a medical and surgical point-of-view is being done for your child so you can stay focused on providing the loving emotional and physical support needed to foster the best healing response possible.