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      Morphological characteristics of the posterior malleolar fragment according to ankle fracture patterns: a computed tomography-based study

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          Abstract

          Background

          The posterior malleolar fragment (PMF) of an ankle fracture can have various shapes depending on the injury mechanism. The purpose of this study was to evaluate the morphological characteristics of the PMF according to the ankle fracture pattern described in the Lauge-Hansen classification by using computed tomography (CT) images.

          Methods

          We retrospectively analyzed CT data of 107 patients (107 ankles) who underwent surgery for trimalleolar fracture from January 2012 to December 2014. The patients were divided into two groups: 76 ankles in the supination-external rotation (SER) stage IV group and 31 ankles in the pronation-external rotation (PER) stage IV group. The PMF type of the two groups was assessed using the Haraguchi and Jan Bartonicek classification. The cross angle (α), fragment length ratio (FLR), fragment area ratio (FAR), sagittal angle (θ), and fragment height (FH) were measured to assess the morphological characteristics of the PMF.

          Results

          The PMF in the SER group mainly had a posterolateral shape, whereas that in the PER group mainly had a posteromedial two-part shape or a large posterolateral triangular shape ( P = 0.02). The average cross angle was not significantly different between the two groups (SER group = 19.4°, PER group = 17.6°). The mean FLR and FH were significantly larger in the PER group than in the SER group ( P = 0.024, P = 0.006). The mean fragment sagittal angle in the PER group was significantly smaller than that in the SER group ( P = 0.017).

          Conclusions

          With regard to the articular involvement, volume, and vertical nature, the SER-type fracture tends to have a smaller fragment due to the rotational force, whereas the PER-type fracture tends to have a larger fragment due to the combination of rotational and axial forces.

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          Most cited references25

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          Adult ankle fractures--an increasing problem?

          The epidemiology of ankle fractures is changing. Increasing longevity has resulted in the highest age-specific incidence of ankle fractures being in women between 75 and 84 years of age. The introduction of the AO classification has facilitated analysis of the commonest fracture types. This survey of 1,500 ankle fractures, seen in a 3-year period in the Edinburgh Orthopaedic Trauma Unit, shows that the commonest ankle fractures are the B1.1 and A1.2 lateral malleolar fractures. Isolated malleolar fractures accounted for two thirds of the series, with bimalleolar fractures occurring in one fourth of the patients and trimalleolar fractures in the remaining 7%. Open fractures occurred in 2%.
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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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              Epidemiology of ankle fractures in Rochester, Minnesota.

              The epidemiology of ankle fractures was examined among Rochester, Minnesota, residents during the 3-year period 1979-1981. Ankle fractures occurred with an overall age- and sex-adjusted incidence rate of 187 per 100,000 person-years; this is higher than in earlier population-based studies. The most frequent cause of ankle fractures was sports-related trauma. The incidence of fractures associated with moderate trauma, on the other hand, increased markedly in middle-aged women, but declined in elderly women. Diabetes mellitus and obesity were associated with fractures in middle-aged and older adults. Of accepted classifications, the Lauge-Hansen system provided the most clinically relevant information.
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                Author and article information

                Contributors
                20vvin@naver.com
                orthochun@gmail.com
                orthowon@gmail.com
                suyeon1002@schmc.ac.kr
                snnov9@hallym.or.kr
                hohotoy@nate.com
                Journal
                BMC Musculoskelet Disord
                BMC Musculoskelet Disord
                BMC Musculoskeletal Disorders
                BioMed Central (London )
                1471-2474
                13 February 2018
                13 February 2018
                2018
                : 19
                : 51
                Affiliations
                [1 ]ISNI 0000 0004 0485 4871, GRID grid.411635.4, Seoul Foot and Ankle Center, Inje University Seoul Paik Hospital, ; Seoul, Republic of Korea
                [2 ]ISNI 0000 0004 1773 6524, GRID grid.412674.2, Department of Orthopedic Surgery, , Seoul Hospital, Soonchunhyang University College of Medicine, ; Seoul, Republic of Korea
                [3 ]ISNI 0000 0004 1773 6524, GRID grid.412674.2, Department of Biostatistics, , Seoul Hospital, Soonchunhyang University College of Medicine, ; Seoul, Republic of Korea
                [4 ]Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheoni-si, Gangwon-do 200-704 Republic of Korea
                Article
                1974
                10.1186/s12891-018-1974-1
                5811968
                29439685
                e7f54fc4-e74d-456a-a96d-3eceabfceeb5
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 17 September 2017
                : 8 February 2018
                Funding
                Funded by: Hallym University Research Fund
                Award ID: HURF-2016-22
                Award Recipient :
                Funded by: Soonchunhyang University Hospital
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Orthopedics
                ankle fracture,computed tomography,posterior malleolar fragment,morphology
                Orthopedics
                ankle fracture, computed tomography, posterior malleolar fragment, morphology

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