A systematic review of posterior pilon fractures

Joseph Boesel; Dominique DiGiacomo; Brett Hoffman; Jiayong Liu

doi:10.1016/j.jor.2025.01.034

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68 (); 34-39

doi:

10.1016/j.jor.2025.01.034

A systematic review of posterior pilon fractures

Joseph Boesel^a, Dominique DiGiacomo^a, Brett Hoffman^a, Jiayong Liu^b,

a The University of Toledo College of Medicine and Life Sciences, USA

b The University of Toledo Medical Center, Department of Orthopaedic Surgery, USA

⁎Corresponding author: Jiayong Liu. jiayong.liu@utoledo.edu

Received: 2025-1-23, Accepted: 2025-1-27, Published: 2025-1-28

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Posterior pilon fractures (PPFs) are intra-articular ankle injuries of the posterior aspect of the distal tibia, often caused by high-energy mechanisms of trauma such as falling from high heights or motor vehicular accidents. However, the definition, mechanism, classification, and surgical approach for fractures have not been thoroughly investigated. This study aims to explore current literature to expand the understanding of this fracture to help physicians achieve better treatment outcomes. Keywords such as “posterior pilon,” “surgical approach,” “fracture,” etc., were used to find relevant literature on PubMed, MEDLINE, Embase, and the Web of Science. Inclusion criteria involved studies discussing PPFs and retrospective and prospective cohort studies. Exclusion criteria included non-English-published papers, anatomical or biomechanical studies, and studies not discussing PPFs. General demographics, complications, and the American Orthopaedic Foot and Ankle Society (AOFAS) functional outcome scores were collected. A total of 18 publications were selected for data collection, most of which were retrospective studies. The articles discussed 959 (Male: 430, Female: 529) patients. PPFs are defined as distal tibia fractures involving impaction of the articular surface and proximal displacement of talus and posterior malleolus fragments. This characteristic fracture is caused by high-energy rotational and axial load. Five studies in this review describe a classification system for ankle fractures that include studies from Klammer (2013), Bartoníček (2015), Mason (2017), Zhang (2018), and Wang (2020). The posterolateral (PL) approach was used in 34.9 % of cases, followed by the posteromedial (PM) in 7.9 %, modified PM in 20.7 %, and combined PM and PL approach in 6.9 % of cases. PPFs are breaks that occur in the posterior half of the articular surface of the distal tibia, typically affecting the weight-bearing area. These fractures result from a combination of rotational and axial loads, leading to intra-articular ankle fractures that often involve a sizeable posterior fragment. Five classification systems for PPFs identify characteristics observable in X-rays, CT scans, or through morphological analysis. The posterolateral (PL) approach was used more than the posteromedial approach. Common complications included malreduction, nerve injuries, and post-operative pain.

Level of Evidence: III.

Keywords

Posterior pilon fracture

Classification system

Mechanism

Surgical approach

Outcomes

Show Related Articles from PubMed

1 Introduction

High-impact distal tibia fractures are challenging to treat due to the complexities of the ankle architecture. A subtype of the trimalleolar fracture has been identified, and the posterior pilon fracture (PPF) has been named. However, due to its similarity to a regular posterior malleolar fracture, the PPF has been hard to distinguish amongst clinicians. Classification systems describing ankle fractures date back to the 1950s when Lauge-Hansen set the foundation for characteristic ankle fractures.¹ With the advancement of surgical techniques and imaging modalities, fractures can be more accurately assessed and treated accordingly. By defining the fracture through radiographs and mechanism, standardized treatment can be achieved to improve patient outcomes.

In 2013, the first classification system for the posterior pilon was published.² Since then, researchers have created systems with specific criteria that aids in the diagnosis of the PPF.^3–6 These systems standardize the approach in classifying various ankle fractures and can help guide clinical treatment. Although this may be beneficial, multiple different classification systems lead to confusion surrounding the PPF and controversy about the exact definition. Thus, there is a need to condense the current understanding of the PPF to resolve some of the debated aspects of the fracture.

The current study systematically reviews the most up-to-date literature regarding PPF. The aim of this study is to clarify the definition, mechanism, classification, treatment methods, and outcomes of the PPF. Since the fracture has a relatively low incidence, many clinicians diagnose it as a classic posterior malleolus fracture, which can lead to improper treatment.⁶ A correct diagnosis and surgical approach will minimize the adverse surgical effects. With a comprehensive review of the PPF, we hope to expand the understanding of this fracture, so physicians are better equipped to recognize, diagnose, and adequately treat the PPF.

2 Methods

2.1

2.1 Search strategy and criteria

A systematic review of current literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. PubMed, MEDLINE, Embase, and Web of Science were used to compile a complete collection of papers covering the surgical techniques used in the treatment of PPFs. Permutations of keywords such as “posterior pilon,” “surgical approach,” “fracture,” etc., were used to find relevant literature. Exclusion criteria included papers not written in English, anatomical studies, biomechanical studies, studies without a function score, and studies not specifically discussing PPFs. After compiling a preliminary list of publications, the authors read each article in its entirety to ensure that collected data would be cohesive and easily analyzable (Fig. 1).

Search strategy for systematic review following PRISMA guidelines.

2.2

2.2 Inclusion criteria

Retrospective and prospective analyses were included, which contained information regarding the definition, classification, mechanism, treatment, and/or outcome of a PPF. Publications were then selected based on their methodology and data collected. Key data points included the AOFAS function score (ranging from 0 to 100, with healthy ankles receiving 100 points) and complications (superficial/deep infection, non/malunion, and osteoarthritis).

2.3

2.3 Assessment of study quality

Most studies included in this review were retrospective cohort studies of patients who had previously undergone correction of PPF with one of the approaches above. Two of the authors reviewed these publications, and disagreements were deferred to the judgment of the first author.

2.4

2.4 Data collection and abstraction

Data collection involved reading and recording data from the articles previously selected for inclusion. Data collected on each study's demographics included the total number of patients, biological sex, and age of the patients. The cause of injury events for each patient were also considered and recorded. Complications such as superficial/deep infection, non/malunion, and osteoarthritis were collected for postoperative follow-up data. This review focused on the most common and well-documented surgical complications. The last data category that was addressed was the AOFAS Function score. These scores range from 0 to 100, with healthy ankles receiving 100 points. Papers included for data collection did not always mention all the variables collected for this analysis. To address these inconsistencies, each data category included the total number of patients for which the data in question was available.

3 Results

A total of 18 publications (959 patients; Male: 430, Female: 529), most of which were retrospective studies, were selected for data collection. There were 5 publications from 2013 to 2020 focused on describing the PPF with a classification system.^2–4^,⁶^,⁷ The other 13 articles were published between 2010 and 2023 and discussed various surgical approaches or treatments of the PPF⁵^,^8–19 (Table 1). The most common outcome measurement reported was the AOFAS score, which evaluates patient outcomes on a scale from 0 to 100. In this review, patients had a combined post-operative AOFAS function score of 84.8 when the PPF was fixed with surgical techniques.

Table 1 Characteristics of the included studies used for data collection.

Author, year	Journal	Design	LOE (Level of evidence)	Approach	No. Of Patients (Male/Female)	Article Category
Bartoníček, 2015	Arch Orthop Trauma	Case series	IV	PL or PM	141 (63/78)	Classification of fracture
Wang, 2020	Br J Radiol	Comparative Study	III	n/a – only classified fracture	174 (88/86)	Classification of fracture
Klammer, 2013	Exp Ther Med	Retrospective Case Series	IV	PL	11 (2/9)	Classification of fracture
Zhang, 2019	Medicine	Retrospective Case Series	IV	PL, PL + PM	36 (18/18)	Classification of fracture
Mason, 2017	Foot Ankle Int.	Comparative Study	III	n/a – only classified fracture	121 (49/72)	Classification of fracture
Zhang, 2022	Chin J Traumatol	Retrospective Case Series	IV	modified PM	20 (7/13)	Surgical Approach/Treatment
Chaparro, 2019	Injury	Case Series	IV	modified PM, PL	25 (6/19)	Surgical Approach/Treatment
Gan, 2022	Injury	Retrospective review	III	Compared PA to TF	85 (30/55)	Surgical Approach/Treatment
Qing, 2023	Injury	Retrospective case series	IV	combined PL and PM	12 (4/8)	Surgical Approach/Treatment
Assal, 2014	J Orthop Trauma	Case-control	III	modified PM (medial to the Achilles tendon)	6 (4/2)	Surgical Approach/Treatment
Jiang, 2022	J Orthop Surg Res	Retrospective case review	IV	Compared OFFL to PL	59 (28/31)	Surgical Approach/Treatment
Gao, 2019	Exp Ther Med	Case-control	III	PL	23 (9/14)	Surgical Approach/Treatment
Liang, 2023	Front Surg	Retrospective case review	IV	PL vs. SL	41 (26/15)	Surgical Approach/Treatment
Huang, 2022	BMC MSK Disorders	Retrospective case review	IV	PL, modified PM, single anterior approach	22 (16/6)	Surgical Approach/Treatment
Lou, 2022	Injury	Retrospective comparative study	IV	n/a	142 (65/77)	Surgical Approach/Treatment
Chen, 2014	Acta Orthop Bras.	Retrospective study	IV	PL, PL + PM	10 (7/3)	Surgical Approach/Treatment
Amorosa, 2010	J Orthop Trauma	Case-control	III	PL, PM, both PL + PM	15 (4/11)	Surgical Approach/Treatment
Wang, 2016	BMC MSK Disorders	Case-control	III	Modified PM	16 (4/12)	Surgical Approach/Treatment

3.1

3.1 Definition

The definition of the PPF is still not very clear. The current understanding of the PPF includes a trimalleolar subtype that involves most of the posterior tibialis lip.² It extends into the posterior half of the medial malleolus (posterior colliculus), and typically contains two fragments. A characteristic double-contour sign on anteroposterior radiographs has helped to classify the PPF radiologically.²⁰ These fractures arise due to a combination of rotational and axial load, which are more common in female and elderly patients.⁸ Since the posterior pilon is largely confused with the posterior malleolus fracture, unique features such as a fragment that enters the coronal plane⁴ or fractures involving only the posterior articular surface of the distal tibia¹² are important in correctly identifying the fracture. In summary, PPFs are breaks that occur in the posterior half of the articular surface of the distal tibia, typically affecting the weight-bearing area.

3.2

3.2 Classification

Recent research has focused on placing the fracture into a classification system with criteria that distinguish it from other fractures.⁶ This subset of fractures was first classified in 2013 by Klammer et al., who described three types of PPFs, increasing complexity. Klammer type 1 included a single medially based fragment and was treated with the PL approach; type 2 involved a split posterior fragment with possible PM comminution and was treated with an additional PM approach, and type 3 involved an anteromedial fragment which was fixed with a medial approach.² The Bartoníček classification system used CT scans to develop a system that categorizes fractures that have a posterior tibial fragment. The type III fracture included a two-part PM fragment involving the malleolus.³ This type of Bartoníček fracture class corresponds to the Haraguchi type II fracture, consistent with the PPF.²¹

Another study, published by Mason et al., in 2017, proposed a classification system to group different patterns of the posterior malleolus fracture, indicating the severity and pathomechanics of the fracture. The type 3 fracture is characterized by a coronal plane fracture line involving the entire posterior plafond and was termed the ‘true posterior pilon fracture’.⁴ Yet another classification system came out in 2019 describing PPFs based on morphology and type of management. The Zhang system grouped PPFs into three groups. This system differentiates the posterior pilon from the trimalleolar or classic pilon fractures and, much like the Klammer system, discusses surgical approaches to the PPF patterns.⁷ Finally, Wang et al. used radiographs to distinguish the posterior pilon from the medial malleolus fracture based on morphology to guide treatment options. An in-depth review of radiographs revealed the PPF has a greater depth and alpha angle of the ankle mortise.¹⁹ These are likely due to combined rotational and vertical forces, creating this characteristic fracture.

3.3

3.3 Mechanism

Injuries leading to a PPF typically involve high-energy events with some rotational and axial load combination.⁸^,¹⁷ These mainly occur when the foot is plantar flexed, creating a posterior fracture.¹² The most common injury event was a fall from height, which occurred in 55 % of the patients, followed by a motor vehicle accident (MVA) at 23 %. There were 8.5 % of fractures that did not report how they occurred in patients. A twisting injury was seen in just over 5 % of cases, while sports injuries accounted for 3 % of injuries. Other events containing <2 % of cases included walking, heavy injury, plantar flexion when falling, crush, hang gliding, motorcycle accident, and being struck by a moving vehicle (Table 2).

Table 2 Injury events leading to posterior pilon fracture.

	Total	Percent
Fall from height	259	55.1 %
MVA	109	23.2 %
Unrecorded	40	8.51 %
Twist	24	5.11 %
Sports	15	3.19 %
Walking	8	1.70 %
Heavy injury	5	1.06 %
Plantar flexion when falling	4	0.85 %
Crush	3	0.64 %
Hang Gliding	1	0.21 %
Motorcycle accident	1	0.21 %
Struck by a moving vehicle	1	0.21 %
Total	470

3.4

3.4 Surgical approach

The PL technique is the most frequently utilized approaches to fix the PPF, implemented in 34.9 % of cases. The PM approach was used in approximately 7.9 % of cases. This PM approach is commonly modified (20.7 %) to include a transverse incision distal to the medial malleolus. Combined PM and PL approaches accounted for 6.9 % of cases in this study. Less frequent approaches included open fibular fracture line (OFFL) (5.9 %), trans-fibular (4.4 %), single lateral (4.0 %), and single anterior approaches (0.6 %) (Table 3).

Table 3 Surgical approaches used to fix the posterior pilon fracture.

Approach	Total	Percent
Posterolateral	182	34.9 %
Modified Posteromedial	108	20.7 %
Posteromedial	41	7.9 %
Posterolateral + Posteromedial	36	6.9 %
Open fibula fracture line	31	5.9 %
Trans-fibular	23	4.4 %
Single lateral	21	4.0 %
Single Anterior	3	0.6 %
TOTAL	522

3.5

3.5 Complications

After analyzing the data, there were 959 patients included, with 69 reported complications after surgical reduction of the posterior pilon. These complications included malreduction (10.2 %), nerve injuries (7.3 %), post-operative pain (6.7 %), skin necrosis (4.9 %), osteoarthritis (4.8 %), superficial or deep infection (2.0 %), nonunion (1.7 %), and other complications (9.9 %). Complications included in the other category included posterior tibial tendon irritation, postoperative screw loosening, unspecified soft tissue injury, and delayed wound healing due to diabetes (Table 4).

Table 4 Complications for posterior pilon surgery.

	Number of events	Total	Percent
Nonunion	5	289	1.7 %
Malreduction	13	127	10.2 %
Infection (deep or superficial)	9	441	2.0 %
Osteoarthritis	9	188	4.8 %
Post-operative pain	10	150	6.7 %
Nerve injuries	6	82	7.3 %
Skin necrosis	5	102	4.9 %
Other	12	121	9.9 %

4 Discussion

Due to the rarity and underappreciation of the PPF, the fracture is commonly misdiagnosed.⁶ Since the identification of the fracture in 2000 by Hansen, there remains a lack of consensus in the scientific community regarding the definition, classification, as well as surgical approach to fix this fracture.²² These results provide a condensed version of the current understanding surrounding the PPF, helping spread information to make this fracture pattern become more well-recognized.

Most commonly, the PPF is caused by violent rotation and vertical compression from a MVA or fall from height. Imaging reveals posterior disruption of the distal tibia involving most of the weight-bearing surface that normally articulates with the talus. In these injuries, the ankle is plantar flexed, and the foot is inverted so that when the lateral edge of the foot touches the ground, the body creates outward forces to the lateral and posterior malleoli. The oblique fracture involves the coronal plane of the posterior malleolus and is referred to as the posterior pilon fracture.⁷ These fractures involve the coronal plane and/or most of the tibialis lip, which are key differences that help distinguish between a posterior malleolus fracture and a PPF.⁴^,¹²

Additionally, PPFs mainly affect the weight-bearing area of the articular surface of the distal tibia. ORIF is the favored approach for treating PPFs due to its ability to provide direct visualization of the fracture site, effectively restoring joint congruency and preventing post-traumatic arthritis.²³ Furthermore, inadequate fixation of the fracture can give rise to poor long-term outcomes, such as increased rates of joint degeneration and functional impairment.²⁴ ORIF provides optimal outcomes for the restoration of the high-load-bearing capabilities of the ankle joint.

Classification systems ideally provide physicians with standardized treatment methods that reduce complications and optimize outcomes for their patients. Multiple systems inherently create ambiguity. One such point of conflict involves the idea that PPFs are defined by Bartoníček type III fractures, which correlate to Haraguchi type II fractures.²¹ Interestingly, Mason declares that there is no Haraguchi classification for the PPF. Instead, the Haraguchi type II fracture would fall under the Mason Type 2 B, involving both PM and PL fragments. While his Mason type III pattern contains the true PPF, defined by a fracture along the coronal plane line involving the entire posterior plafond.⁴ Such conflict needs to be clarified so the posterior pilon fracture can be defined as involving the posterior colliculus and disruption of the weight-bearing aspect of the distal tibia.

Surgical approaches for fixing the fracture have also been debated as clinicians find the approach that provides optimal outcomes. The PL approach is currently the most commonly used to fix the PPF. The PL technique uses a longitudinal incision immediately lateral to the Achilles tendon, and the sural nerve must be identified and protected.² Common risks include injury to the sural nerve and perforating branch of the peritoneal artery,²^,²⁵ which can be reduced by adopting the modified PM approach.¹⁹ This approach contains a longitudinal incision between the Achilles and PM border of the distal tibia, allowing for adequate exposure to reduce posterior fragments and the medial malleolus.³ However, the modified PM approach is limited by the lack of visualization of the articular surface after reduction.⁸ At times, surgeons have opted to combine both the PM and PL approaches to gain access to both fragments for fixation under direct vision.⁷^,¹⁷ The OFFL technique involves creating an open line of exposure along the fibula for precise fracture management, however, there is reported difficulty in achieving optimal alignment and fixation.¹² Much like the OFFL, the single lateral approach exposes the articular surface of the distal tibia with a lateral incision. This allows for less soft tissue obstruction, but there is still difficulty in accessing the larger posterior fragments.¹⁴^,¹⁸ Comparative studies, including those conducted by Gan (2022), Jiang (2022), and Liang (2023), provide valuable insights into the relative effectiveness of different surgical approaches; however, a larger sample size must be completed to make definitive conclusions.⁹^,¹²^,¹⁴

The retrospective nature of our study is a major limitation as it challenges our ability to establish causal relationships which would be possible in a randomized controlled trial (RCT). Furthermore, while a classification system for fractures was discussed, there still remains a lack of consensus. Currently, five different classification systems are in use, and none of these classification systems have been unanimously agreed upon. This further complicates our study's ability to definitively draw conclusions regarding which approaches are optimal and produce the best outcomes. The studies included in this review contained incomplete data regarding function scores, complications, mechanism of injury, and necessary demographic data which demonstrates another limitation. Future RCTs with standardized methods for treating PPFs and prospective designs are needed to more accurately define which is the most effective method.

5 Conclusion

PPFs are breaks from high-energy events (falls, MVAs, etc.) that occur in the posterior half of the articular surface of the distal tibia, typically affecting the weight-bearing area. While there is no consensus on a standardized classification system used for PPFs, some classification systems rely solely on X-rays to evaluate the depth of injury, while others utilize both x-ray and CT scans. Despite this, the lack of a standardized approach to PPFs creates inconsistency in classification across cases.

CRediT authorship contribution statement

Joseph Boesel: data acquisition, Formal analysis, interpretation of data, article drafting, final approval. Dominique DiGiacomo: Analysing interpreting data, article drafting, final approval. Brett Hoffman: Analysing interpretation of data, critical revision, final approval. Jiayong Liu: Conceptualization, study design, Formal analysis, and interpretation, critical revision & editing, final approval.

Ethical statement

We confirm that all authors have read and approved the manuscript, and no other individuals meet the authorship criteria but are not listed. We have also agreed upon the order of authorship as presented. Furthermore, we assure you that this manuscript has not been submitted elsewhere.

Funding information

This research was conducted independently and did not receive specific funding from public, commercial, or not-for-profit agencies.

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Introduction

Methods

Search strategy and criteria
Inclusion criteria
Assessment of study quality
Data collection and abstraction

Results

Definition
Classification
Mechanism
Surgical approach
Complications

Discussion

Conclusion

CRediT authorship contribution statement

Declaration of patient consent form

Guardian/patient's consent

Ethical statement

Funding information

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[1] Lauge-Hansen N., . Fractures of the ankle. III. Genetic roentgenologic diagnosis of fractures of the ankle. Am J Roentgenol Radium Ther Nucl Med. 1954 Mar;71(3):456-471.
[Google Scholar]

[2] Klammer G., Kadakia A.R., Joos D.A., Seybold J.D., Espinosa N., . Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int. 2013 Feb;34(2):189-199.
[Google Scholar]

[3] Bartonicek J., Rammelt S., Kostlivy K., Vanecek V., Klika D., Tresl I., . Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015 Apr;135(4):505-516.
[Google Scholar]

[4] Mason L.W., Marlow W.J., Widnall J., Molloy A.P., . Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int. 2017 Nov;38(11):1229-1235.
[Google Scholar]

[5] Zhang Z.C., He W.B., Lin H., . Analysis of the efficacy of a modified posteromedial approach for Klammer III posterior Pilon fractures. Chin J Traumatol. 2022 Mar;25(2):83-89.
[Google Scholar]

[6] Wang J., Wang X., Xie L., Zheng W., Chen H., Cai L., . Comparison of radiographs and CT features between posterior Pilon fracture and posterior malleolus fracture: a retrospective cohort study. Br J Radiol. 2020 Jun;93(1110)
[Google Scholar]

[7] Zhang J., Wang H., Pen C., et al . Characteristics and proposed classification system of posterior pilon fractures. Medicine (Baltim). 2019 Jan;98(3)
[Google Scholar]

[8] Chaparro F., Ahumada X., Urbina C., et al . Posterior pilon fracture: epidemiology and surgical technique. Injury. 2019 Dec;50(12):2312-2317.
[Google Scholar]

[9] Gan T.J., Li Y.X., Chen Y., Liu X., Zhang H., . Open reduction and internal fixation for posterior pilon fracture: transfibular approach versus posterior approach. Injury. 2023 Feb;54(2):751-760.
[Google Scholar]

[10] Qing S., Zhang Y., Qin X., . The treatment of a malunited posterior pilon fracture with talar dislocation: a staged surgical treatment protocol. Injury. 2023 Oct;54(10)
[Google Scholar]

[11] Assal M., Ray A., Fasel J.H., Stern R., . A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C) J Orthop Trauma. 2014 Jun;28(6):e138-e145.
[Google Scholar]

[12] Jiang Z., Zhang C., Qin J.J., Wang G.D., Wang H.S., . Posterior pilon fracture treated by opening the fibula fracture gap. J Orthop Surg Res. 2022 Apr 7;17(1):214.
[Google Scholar]

[13] Gao M., Liu N., Cheng Y., Shi W., Yang H., . Treatment outcomes of the posterolateral approach of plate fixation for posterior pilon fractures. Exp Ther Med. 2019 May;17(5):4267-4272.
[Google Scholar]

[14] Liang W., Zhou M., Jiang Z., Mao X., Zhou X., . Treatment outcomes of posterior pilon fractures using a simple single lateral approach via stretching fibular fracture line. Front Surg. 2023;10
[Google Scholar]

[15] Huang M., Wang Q., Guan J., Liu K., Chen Y., Wang L., . Tips and Tricks in surgical reduction of the posterior column of AO/OTA C3 pilon fractures. BMC Muscoskel Disord. 2022 Jan 3;23(1):2.
[Google Scholar]

[16] Lou Z., Wang Z., Liu C., Tang X., . Outcomes of tibial pilon fracture fixation based on four-column theory. Injury. 2023 Apr;54(Suppl 2):S36-S42.
[Google Scholar]

[17] Chen D.W., Li B., Aubeeluck A., Yang Y.F., Zhou J.Q., Yu G.R., . Open reduction and internal fixation of posterior pilon fractures with buttress plate. Acta Ortopédica Bras. 2014;22(1):48-53.
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A systematic review of posterior pilon fractures

Abstract