Associations between Vehicle Safety Systems and Pilon Fracture Severity Are Revealed by Using a Novel Objective Quantitative Fracture Energy Metric

Pilon fractures are a severe lower-extremity injury sustained in motor vehicle crashes, characterized by high-axial loading that drives the talus into the tibial plafond and frequently results in poor long-term functional outcomes and post-traumatic osteoarthritis (PTOA). Despite advances in surgical management, clinical complications remain frequent in 20–50% of cases in literature, which highlights the need to identify modifiable upstream risk factors in the motor vehicle crash environment. The Abbreviated Injury Scale (AIS) is the predominant tool for crash injury severity analysis, and it classifies all closed pilon fractures uniformly as moderate (AIS 2) regardless of comminution or imparted energy and poorly predicts long-term functional outcomes. An existing fracture energy severity metric quantifies the acute mechanical energy delivered to bone during fracture and has been linked to PTOA development. This study represents one of the first multivariate applications of the fracture energy metric to crash data, examining how occupant demographics, crash kinematics, and vehicle safety systems relate to pilon fracture severity. Fifty belted occupants with Orthopaedic Trauma Association (OTA) Type B or Type C pilon fractures were identified through the Crash Injury Research and Engineering Network (CIREN) database. Fracture fragment surface models were generated from clinical computed tomography (CT) and used to compute fracture energy severity through a custom MATLAB script. A generalized linear model with a gamma log link was fit using seven predictors: age, delta-v, knee bolster airbag (KBAB) deployment, fracture loading mechanism, biological sex, osteoporosis, and body mass index (BMI). KBAB deployment and pure axial compression loading were both significantly associated with higher fracture energy (p = 0.011 and p = 0.002), and age approached an inverse association (p = 0.086). These findings establish the fracture energy metric as a viable tool for crash injury analysis and suggest that certain vehicle safety system characteristics warrant further investigation as modifiable factors influencing pilon fracture severity.