J Korean Foot Ankle Soc.  2022 Jun;26(2):59-65. 10.14193/jkfas.2022.26.2.59.

What is the Significance of the Posterior Malleolus in Ankle Fractures?

• Lee J
• Park JY

• KMID: 2530484
• DOI: http://doi.org/10.14193/jkfas.2022.26.2.59

Abstract

The posterior malleolar fracture is relatively common fracture of the foot and ankle, but several aspects of this are still controversial. If the posterior malleolus is involved in the ankle fracture, the prognosis is usually poor. A computed tomography scan is essential for accurate diagnosis and treatment planning. Although indirect reduction and the anterior to posterior screw fixation technique have the advantages of a small incision with the requirement of relatively simple skills, direct open reduction and fixation from the posterior side provide a more biomechanically stable and accurate reduction. The precise reduction of the posterior malleolar fragment helps to achieve congruency of the tibia and fibula in the incisura and contributes to syndesmotic stability. It is important to determine the indications for surgical treatment by comprehensively evaluating the three-dimensional structure of the posterior malleolar fracture and all related injuries to the ankle.

Keyword

Posterior malleolus fractures; Trimalleolar fractures; Ankle fractures

Figure

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  Figure. 1 Haraguchi classification of the posterior malleolar fracture. (A) Type-I, the posterolateral-oblique type. (B) Type-II, the medialextension type. (C) Type-III, the small-shell type.

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  Figure. 2 Bartonicek and Rammelt classification of the posterior malleolar fracture. (A) Type 1, extraincisural fragment with an intact fibular notch. (B) Type 2, posterolateral fragment extending into the fibular notch. (C) Type 3, posteromedial two-part fragment involving the medial malleolus. (D) Type 4, large posterolateral triangular fragment involving more than one-third of the notch. Type 5 is used to describe an irregular osteoporotic fracture that does not match of the any other 4 patterns.

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  Figure. 3 Preoperative images. Anteroposterior (A) and lateral (B) ankle plain radiographs. Axial (C) and sagittal (D) computed tomography scans.

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  Figure. 4 Intraoperative findings. (A) The fibula fracture site was spread using a lamina spreader. (B) The posterior malleolar fracture site was approached through the gap between the fibula fragments, and the bony fragment stuck in the joint was removed.

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  Figure. 5 (A) The fibula fracture site was reduced using a reduction clamp, and (B) the fibula was fixed with a lag screw. (C) While maintaining reduction by pushing the posterior malleolar fragment toward the articular surface with a ball spike pusher, (D) the fragment was fixed in the posterior to anterior direction with a partially threaded screw.

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  Figure. 6 Immediate postoperative anteroposterior (A) and lateral (B) ankle plain radiographs. Postoperative 1-year anteroposterior (C) and lateral (D) ankle plain radiographs. The articular surfaces are well preserved and there is no evidence of post-traumatic arthritis.

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