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      Manejo terapéutico del maléolo posterior en fracturas trimaleolares de tobillo. Revisión bibliográfica Translated title: Therapeutic Management of the Posterior Malleolus in Trimaleolar Ankle Fractures. Review Translated title: Manejo terapêutico do maléolo posterior em fraturas do tornozelo trimaleolar. Revisão bibliográfica

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          Abstract

          Resumen: Introducción : El manejo terapéutico de las fracturas de maléolo posterior en las fracturas trimaleolares de tobillo continúa en debate. Nuestro objetivo fue realizar una búsqueda de la evidencia científica sobre los aspectos terapéuticos de las fracturas de maléolo posterior en el contexto de las fracturas trimaleolares. Materiales y métodos: Se realizó una revisión de la bibliografía sistematizada por dos revisores, centrados en el manejo terapéutico del maléolo posterior. Resultados: Se obtuvieron 16 artículos clínicos de un total de 1029 pacientes, 8 estudios nivel de evidencia II y 8 de nivel IV. Se sistematizaron las indicaciones quirúrgicas y se analizaron los resultados funcionales y las complicaciones. Conclusiones: La comprensión pato-anatómica de estas fracturas es cada día mayor, principalmente por la utilización habitual de tomografías computarizadas (TC). El tratamiento quirúrgico sobre el maléolo posterior está evidenciando buenos y excelentes resultados funcionales. Para una adecuada decisión terapéutica se debería tener en cuenta ciertos factores: inestabilidad tibiotalar y sindesmótica, congruencia articular y características morfológicas del maléolo posterior. La reducción abierta (RA) y fijación interna con placa de sostén es el tratamiento que ha demostrado mejores resultados a corto y mediano plazo, no encontrando estudios con seguimiento a largo plazo.

          Translated abstract

          Abstract: Introduction: The therapeutic management of posterior malleolus fractures in trimaleolar ankle fractures continues in debate. Our objective was to conduct a search for scientific evidence on the therapeutic aspects of posterior malleolus fractures in the context of trimaleolar fractures. Materials and methods: A review systematic of the literature was carried out by two reviewers, focusing on the therapeutic management of the posterior malleolus. Results: 16 clinical articles were obtained with a total of 1029 patients, 8 studies level of evidence II and 8 studies level IV. The surgical indications were systematized, and the functional results and complications were analyzed. Conclusions: The patho-anatomical understanding of these fractures is increasing every day, mainly due to the usual use of CT scans. Surgical treatment on the posterior malleolus shows good and excellent functional results. For an adequate therapeutic decision certain factors should be taken into account: tibiotalar and syndesmotic instability, joint congruence and morphological characteristics of the posterior malleolus. Open reduction and internal fixation with support plate is the treatment that has shown better results in the short and medium term, not finding studies with long-term follow-up.

          Translated abstract

          Resumo: Introdução : O tratamento terapêutico das fraturas do maléolo posterior nas fraturas do tornozelo trimaleolar continua em debate. Nosso objetivo foi realizar uma pesquisa de evidências científicas sobre os aspectos terapêuticos das fraturas do maléolo posterior no contexto das fraturas trimaleolares. Materiais e métodos : Uma revisão sistemática da literatura foi realizada por dois revisores, com foco no manejo terapêutico do maléolo posterior. Resultados: foram obtidos 16 artigos clínicos com um total de 1029 pacientes, 8 estudos com nível de evidência II e 8 estudos com nível IV. As indicações cirúrgicas foram sistematizadas e os resultados e complicações funcionais foram analisados. Conclusões: O entendimento anatomopatológico dessas fraturas está aumentando a cada dia, principalmente devido ao uso habitual de tomografias computadorizadas. O tratamento cirúrgico do maléolo posterior mostra bons e excelentes resultados funcionais. Para uma decisão terapêutica adequada, certos fatores devem ser levados em consideração: instabilidade tibiotalar e sindesmótica, congruência articular e características morfológicas do maléolo posterior. A redução aberta e a fixação interna com placa de suporte é o tratamento que apresenta melhores resultados no curto e médio prazo, não encontrando estudos com acompanhamento a longo prazo.

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          Pathoanatomy of posterior malleolar fractures of the ankle.

          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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            Anatomy and classification of the posterior tibial fragment in ankle fractures.

            The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort.
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              Posterior Malleolar Fractures: Changing Concepts and Recent Developments.

              Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.
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                Author and article information

                Journal
                afm
                Anales de la Facultad de Medicina
                Anfamed
                Universidad de la República. Facultad de Medicina (Montevideo, , Uruguay )
                2301-1254
                2020
                : 7
                : 1
                : 01208
                Affiliations
                [2] orgnameUniversidad de la República orgdiv1Facultad de Medicina orgdiv2Clínica de Traumatología y Ortopedia Uruguay
                [1] orgnameUniversidad de la República orgdiv1Facultad de Medicina Uruguay jpfilippini_02@ 123456hotmail.com
                Article
                S2301-12542020000101208 S2301-1254(20)00700101208
                10.25184/anfamed2020v7n1a6
                8ff5b23a-82f1-4386-9b83-09e8c900dc16

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 04 May 2020
                : 12 March 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 34, Pages: 0
                Product

                SciELO Uruguay

                Categories
                Artículo de Revisión

                fixação interna,fraturas trimalleolares,fraturas malleolares posteriores,maléolo posterior,fixação de fraturas (malha),fraturas do tornozelo (malha),fijación interna.,fracturas trimalleolares,fracturas maleolares posteriores,fijación de fracturas (malla),fracturas de tobillo (malla),Internal Fixation.,Trimalleolar Fractures,Posterior Malleolar Fractures,Posterior Malleolus,Fractures Fixation (Mesh),Ankle Fractures (Mesh)

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