Catastrophic complications from inadequate early soft tissue surveillance in a closed pilon fracture: a case report

We present the case of a 55-year-old man with an AO/OTA 43-C3 pilon fracture in whom initial uniplanar external fixation failed to relieve persistent medial skin tenting, resulting in focal ischemic necrosis. Within 72 hours, the patient developed bullae and violaceous discoloration, which progressed to full-thickness skin breakdown. Despite staged open reduction and internal fixation and fasciocutaneous flap coverage, the patient developed chronic osteomyelitis, ultimately requiring segmental bone resection to control the infection. The patient underwent serial debridement procedures and placement of antibiotic-loaded cement spacers. Definitive reconstruction was achieved with salvage tibiotalocalcaneal arthrodesis using the Expert Tibial Nail system on postoperative day 319. Twelve months after fusion and bone grafting, radiographs confirmed solid union, and the patient was ambulating independently, albeit with considerable long-term functional limitations. This case underscores the importance of early and meticulous soft tissue evaluation in high-energy pilon fractures. Prompt repositioning of fracture fragments or the use of adjunctive decompression is essential. Delayed or inadequate decompression can lead to a cascade of complications, beginning with soft tissue necrosis and progressing to deep infection and limb salvage fusion, even when standard fixation protocols are followed.