Concomitant ipsilateral pilon fracture with a calcaneum fracture is a rare occurrence. In our case, it is also associated with L2 burst fracture with cauda equina syndrome. Pilon fractures are rare, comprising 3–10% of all fractures of the tibia and 1% of all lower extremity fractures. Pilon is the French word for “pestle” and was introduced in 1911 by French radiologist Étienne Destot ^[1]. About 2% of all fractures are calcaneal fractures. However, they make up 60% of fractures of the midfoot bones ^[2].

Pre-operative evaluation

A 33 year old male came with alleged history of fall from electric pole after suffering electric shock and was taken to outside hospital and there he was diagnosed to have compression fracture of L2 (burst type) with right pilon fracture and right calcaneum fracture (sanders type 4) (Fig. 1) and later patient shifted to Apollo hospital neurologically Right hip ⅕ knee ⅕ and ankle 0/5, Left hip 1/5knee ⅕ and ankle 0/5, Perianal sensation decreased. A CT scan was done, suggestive of a displaced fracture medial malleolus and an intra-articular displaced calcaneum fracture (Figs. 2 and 3). Fracture was temporarily stabilized with below knee pop-back slab and limb elevation given. Patient underwent D12–L4 stabilization with dural repair for L2 burst fracture and cauda equina (Fig. 4). For 5 days, patient was optimized in ICU. The patient was planned for definitive fixation of calcaneal and pilon fracture.

Surgical technique

A third-generation cephalosporin was administered for prophylaxis during the induction of general anesthesia. The patient was first placed in a floppy lateral position for reconstruction of the calcaneal fracture. The surgery was performed under tourniquet hemostasis, and a lateral approach was used. A full-thickness subperiosteal flap was raised and reduced with Kirschner wires. The fracture was stabilized with a Locking T plate and screws. Subsequently, the tourniquet was released. Closure done with 2-0 Ethilon and mini VAC kept. The tourniquet was reinflated. The pilon fracture was exposed through an anteromedial incision, with care taken to minimize soft-tissue dissection. The fracture was reduced temporarily with K wires and fixed with an AO cruciate locking T plate and LC DCP Plate and screws. Cancellous bone graft was harvested from the ipsilateral iliac crest to support the articular surface (Fig. 5). Closure was done with 2-0 Ethilon. Below Knee- Back slab applied.

Postoperative period

Postoperative radiograph (Fig. 6) showed stable fixation.

In the postoperative period, the left lower limb was kept elevated and, after swelling had reduced, a cast was applied. At the time of discharge, power of lower limbs improved to grade 3. Mobilization of the ankle and subtalar joints was initiated once the incisions had healed. The patient received physiotherapy treatment for 6 months. After discharge from the hospital, the patient was followed regularly for clinical and radiographic assessment in the outpatient clinic. The patient had good neurological recovery and regained bowel and bladder control. For the first 2 months, the patient was kept non-weight bearing on the right lower limb. He then gradually progressed to full weight bearing. 3 months postoperative, both fractures had gone on to unite clinically and radiologically. At final follow-up, after surgery, there was no radiographic evidence of posttraumatic osteoarthritis (Fig. 7).

Immediate post-operative shows acceptable Calcaneal height, but it is reduced later on which is common in comminuted calcaneal fracture.

The patient had terminal restriction of range of motion of both the ankle and the subtalar joints (Fig. 8 and 9).

The patient had full neurological recovery at 9 months of follow-up. At 1-year follow-up, radiograph shows complete radiological union, and the patient did not have any further loss in calcaneal height (Fig. 10).

The timing of surgery becomes critical in achieving a good outcome and to reduced complications. The historically high rates of infection associated with open reduction and internal fixation of pilon fractures may be due to attempts at immediate fixation through swollen, compromised soft tissues ^[3]. Hence, it is important to wait for the development of wrinkle in skin “wrinkling of the skin” seems to be the best indicator for deciding surgery, which in most cases will occur ~10–14 days after the trauma ^[4]. The location of the blisters might also limit surgical approaches ^[5]. In a prospective study of 53 cases complicated by fracture blisters, Giordano and Koval found no significant difference in outcome whether the blisters were aspirated, de-roofed, or left intact. 2 cases of wound infection occurred when an incision was made directly through blood-filled blisters ^[6]. Hence, we applied a temporary splint and kept the limb elevated and delayed our surgery by 5 days. The results of ORIF and EFLIF in the treatment of high-energy pilon fractures are equally effective in terms of functional outcomes and complication rates in the short term ^[7]. Conventional radiographs are limited for visualization of the calcaneal anatomy, especially at the subtalar joint. A CT scan is currently the imaging study of choice for evaluating calcaneal injury and has substituted conventional radiography in the classification of calcaneal fractures ^[8]. In a study of 26 distal tibial explosion fractures in 24 patients results of operative treatment were, however, superior to the results of non-operative treatment. Adequate treatment consists of anatomic reconstruction of the distal tibia, rigid internal fixation, early active motion, and nonweight bearing in 3–5 months ^[9]. A strong Axial load is the reason for the development of ipsilateral pilon fracture and calcaneum fracture as proven by a cadaveric study, Yoganandan et al. ^[10]. The occurrence of deep vein thrombosis in trauma patients is high, with the incidence ranging from 20 to 90% ^[11]. Anatomic open reduction and stable internal fixation led to an excellent result in this particular patient at a follow-up of 9 months ^[12]. These fractures are better treated either with external fixation or with open reduction and internal fixation techniques, depending on the surgeon’s preference and the fracture configuration ^[13].

The timing of surgery, surgical technique, method of fixation, and early mobilization play an important role in achieving a good functional outcome and to reduce the chances of infection.

Comprehensive radiological evaluation with appropriately timed surgical intervention with an anatomical fixation with appropriate implants and early mobilsation are the key to achieve good functional outcome.