Posterior malleolus fractures

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Abstract

The posterior malleolus component of a fracture of the ankle is important, yet often overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not used enough. Posterior malleolus fractures are not difficult to fix. After reduction and fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered. Cite this article: Bone Joint J 2017;99-B:1413-19.

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Most cited references 47

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The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up.

H Sagi, Anjan R Shah, Roy Sanders (2012)

To examine the correlation between syndesmotic malreduction and functional outcome.

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Pathoanatomy of posterior malleolar fractures of the ankle.

Naoki Haraguchi, Hiroki Haruyama, Hidekazu Toga … (2006)

The functional outcome following ankle fractures that involve a posterior malleolar fragment is often not satisfactory, and treatment of this type of fracture remains controversial. Thorough knowledge of the pathologic anatomy of the posterior malleolar fracture is essential for planning appropriate treatment. Thus, we conducted a computed tomographic study to clarify the pathologic anatomy of the posterior malleolar fracture. Between 1999 and 2003, fifty-seven consecutive patients with a unilateral ankle fracture with one or more posterior fragments were managed at our hospital. We reviewed the patients' preoperative computed tomographic scans to determine (1) the ratio of the posterior fragment area to the total cross-sectional area of the tibial plafond and (2) the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond. The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). Two of the eleven medial-extension fractures extended to the anterior part of the medial malleolus. A total of nine of the eleven medial-extension fractures actually consisted of two fragments [corrected] The conditions are not exclusive of one another; for example, in the case of one of the fractures exhibiting two fragments, the fracture also extended to the anterior part of the medial malleolus [corrected] The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus varied. The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. The information obtained from this study will be helpful for conducting basic research of this condition and for determining appropriate surgical approaches.

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Fixation of posterior malleolar fractures provides greater syndesmotic stability.

M. Gardner, Jason H. Nielson, Geoffrey S. Briggs … (2006)

Syndesmotic injuries are common in ankle fractures. Traditional syndesmosis fixation may be associated with a secondary procedure. When the posterior malleolus is fractured, the posterior syndesmotic ligaments may remain intact and attached to the fragment. Our goals were to establish the incidence of syndesmotic ligament ruptures in pronation-external rotation type ankle injuries associated with posterior malleolar fractures, and to assess syndesmotic stability after fixation of the posterior malleolus compared with using a syndesmotic screw. Fifteen patients who sustained pronation-external rotation Stage 4 ankle fractures that involved the posterior malleolus were evaluated using radiographs and magnetic resonance imaging. No complete tears of the posterior-inferior tibiofibular ligament occurred. A pronation-external rotation fracture pattern with a posterior malleolar fragment was created in 10 lower extremity cadaver specimens with random fixation of the posterior malleolus or the syndesmosis. Compared with the intact specimens, stiffness was restored to 70% after fixation of the posterior malleolus, and to 40% after syndesmosis stabilization. Syndesmotic stability may be obtained more effectively by fixation of the posterior malleolus rather than by using a syndesmotic screw. Although additional clinical investigation is warranted, these concepts may be useful in eliminating syndesmotic screw fixation in select patients.

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Author and article information

Journal

Title: The Bone & Joint Journal

Abbreviated Title: The Bone & Joint Journal

Publisher: British Editorial Society of Bone & Joint Surgery

ISSN (Print): 2049-4394

ISSN (Electronic): 2049-4408

Publication date Created: November 2017

Publication date (Print): November 2017

Volume: 99-B

Issue: 11

Pages: 1413-1419

Affiliations

[1 ]Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK

[2 ]Frimley Park Hospital, Portsmouth Road, Frimley, Surrey GU16 7UJ, UK

Article

DOI: 10.1302/0301-620X.99B11.BJJ-2017-1072

PubMed ID: 29092978

SO-VID: 77eb8465-db5c-4a4c-835e-471a83497471

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Posterior malleolus fractures : worth fixing

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Most cited references 47

The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up.

Pathoanatomy of posterior malleolar fractures of the ankle.

Fixation of posterior malleolar fractures provides greater syndesmotic stability.

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