Archives of Orthopaedic and Trauma Surgery

, Volume 138, Issue 9, pp 1213–1222 | Cite as

When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review

  • Samuel Marinus Verhage
  • Jochem Maarten Hoogendoorn
  • Pieta Krijnen
  • Inger Birgitta Schipper
Trauma Surgery



Whether or not and how to fixate the posterior malleolus fracture seems to depend on the fracture fragment size and its amount of dislocation, but clear guidelines for daily practice are lacking. In this review, we summarize the literature on preferred treatment of the posterior fragment in trimalleolar fractures.


A systematic review of publications between January 1995 and April 30 2017 on this topic in the PubMed, Embase, and Cochrane databases was performed according to the PRISMA statement.


Seventeen (2 prospective and 15 retrospective) of the 180 identified studies were included. Six studies report on indications for fixation of posterior malleolus fracture fragments. Eleven studies compare different fixation approaches and techniques for the posterior fragment. Meta-analysis was not possible due to varying fixation criteria and outcomes. There was no clear association between posterior fragment size and functional outcome or development of osteoarthritis. The non-anatomical reduction of the fragment was of more influence on outcome. Radiological and functional outcome was better after open reduction and internal fixation via the posterolateral approach than after percutaneous anterior-to-posterior screw fixation.


The posterior fragment size is not a clear indication for its fixation. A step-off, however, seems an important indicator for developing posttraumatic osteoarthritis and worse functional outcome. Posterior fragments involving the intra-articular surface need to be reduced and fixated to prevent postoperative persisting step-off. Furthermore, fixation of the posterior malleolus via an open posterolateral approach seems superior to percutaneous anterior-to-posterior fixation. However, these results need to be confirmed in a prospective comparative trial.

Level of evidence

Therapeutic level II.


Trimalleolar fractures Malleolar fractures Posterolateral approach Ankle fractures Treatment Fixation 



There is no funding source.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Court-Brown CM, McBirnie J, Wilson G (1998) Adult ankle fractures—an increasing problem? Acta Orthop Scand 69(1):43–47CrossRefPubMedGoogle Scholar
  2. 2.
    McDaniel WJ, Wilson FC (1977) Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res 122:37–45Google Scholar
  3. 3.
    Broos PL, Bisschop AP (1991) Operative treatment of ankle fractures in adults: correlation between types of fracture and final results. Injury 22(5):403–406CrossRefPubMedGoogle Scholar
  4. 4.
    Lindsjö U (1985) Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res. 199:28–38Google Scholar
  5. 5.
    Jaskulka RA, Ittner G, Schedl R (1989) Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 29(11):1565–1570CrossRefPubMedGoogle Scholar
  6. 6.
    Langenhuijsen JF, Heetveld MJ, Ultee JM et al (2002) Results of ankle fractures with involvement of the posterior tibial margin. J Trauma 53(1):55–60CrossRefPubMedGoogle Scholar
  7. 7.
    De Vries JS, Wijgman AJ, Sierevelt IN et al (2005) Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 44(3):211–217CrossRefPubMedGoogle Scholar
  8. 8.
    Verhage SM, Schipper IB, Hoogendoorn JM (2015) Long-term functional and radiographic outcomes in 243 operated ankle fractures. J Foot Ankle Res 8:45CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM (2015) Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. Foot Ankle Int 36(6):673–678CrossRefGoogle Scholar
  10. 10.
    Xu HL, Li X, Zhang DY et al (2012) A retrospective study of posterior malleolus fractures. Int Orthop 36(9):1929–1936CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bartonicek J, Rammelt S, Tucek M (2017) Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 22(1):125–145CrossRefPubMedGoogle Scholar
  12. 12.
    Talbot M, Steenblock TR, Cole PA (2005) Posterolateral approach for open reduction and internal fixation of trimalleolar ankle fractures. Can J Surg 48(6):487–490PubMedPubMedCentralGoogle Scholar
  13. 13.
    Tornetta P 3rd, Ricci W, Nork S et al (2011) The posterolateral approach to the tibia for displaced posterior malleolar injuries. J Orthop Trauma 25(2):123–126CrossRefPubMedGoogle Scholar
  14. 14.
    Odak S, Ahluwalia R, Unnikrishnan P et al (2016) Management of posterior malleolar factures: a systematic review. J Foot Ankle Surg 55(1):140–145CrossRefPubMedGoogle Scholar
  15. 15.
    Fu S, Zou ZY, Mei G et al (2013) Advances and disputes of posterior malleolus fracture. Chin Med J (Engl) 126(20):3972–3977Google Scholar
  16. 16.
    Irwin TA, Lien J, Kadakia AR (2013) Posterior malleolus fracture. J Am Acad Orthop Surg 21(1):32–40CrossRefPubMedGoogle Scholar
  17. 17.
    Zhong S, Shen L, Zhao JG et al (2017) Comparison of posteromedial versus posterolateral approach for posterior malleolus fixation in trimalleolar ankle fractures. Orthop Surg 9(1):69–76CrossRefPubMedGoogle Scholar
  18. 18.
    Kim MB, Lee YH, Kim JH et al (2015) Lateral transmalleolar approach and miniscrews fixation for displaced posterolateral fragments of posterior malleolus fractures in adults: a consecutive study. J Orthop Trauma 29(2):105–109CrossRefPubMedGoogle Scholar
  19. 19.
    Moher D, Liberati A, Tetzlaff J, PRISMA Group et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269CrossRefPubMedGoogle Scholar
  20. 20.
    Mingo-Robinet J, López-Durán L, Galeote JE et al (2011) Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg 50(2):141–145CrossRefPubMedGoogle Scholar
  21. 21.
    Evers J, Barz L, Grüneweller N et al (2015) Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar fractures. Injury 46(4):109–113CrossRefGoogle Scholar
  22. 22.
    Verhage SM, Boot F, Schipper IB et al (2016) Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone JJ 98-B(6):812–817CrossRefGoogle Scholar
  23. 23.
    Abdelgawad AA, Kadous A, Kanlic E (2011) Posterolateral approach for treatment of posterior malleolus fracture of the ankle. J Foot Ankle Surg 50(5):607–611CrossRefPubMedGoogle Scholar
  24. 24.
    Ruokun H, Ming X, Zhihong X et al (2014) Postoperative radiograph and clinical assessment of the treatment of posterior tibial plafond fractures using a posterior lateral incisional approach. J Foot Ankle Surg 53(6):678–682CrossRefPubMedGoogle Scholar
  25. 25.
    Forberger J, Sabandal PV, Dietrich M et al (2009) Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity. Foot Ankle Int 30(4):309–314CrossRefPubMedGoogle Scholar
  26. 26.
    Karaca S, Enercan M, Özdemir G et al (2016) Importance of fixation of posterior malleolus fracture in trimalleolar fractures: a retrospective study. Ulus Travma Acil Cerrahi Derg 22(6):553–558PubMedGoogle Scholar
  27. 27.
    Huber M, Stutz PM, Gerber C (1996) Open reduction and internal fixation of the posterior malleolus with a posterior antiglide using a posterolateral approach, a preliminary report. Foot Ankle Surg 2(2):95–103CrossRefGoogle Scholar
  28. 28.
    Shi H, Xiong J, Chen Y et al (2017) Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord 18(1):109CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    O’Connor TJ, Mueller B, Ly TV et al (2015) “A to P” screw versus posterolateral plate for posterior malleolus fixation in trimalleolar fractures. J Orthop Trauma 29(4):151–156CrossRefGoogle Scholar
  30. 30.
    Erdem MN, Erken HY, Burc H et al (2014) Comparison of lag screw versus buttress plate fixation of posterior malleolar fractures. Foot Ankle Int 35(10):1022–1030CrossRefPubMedGoogle Scholar
  31. 31.
    Miller AG, Margules A, Raikin SM (2012) Risk factors for wound complications after ankle surgery. J Bone Jt Surg Am 94(22):2047–2052CrossRefGoogle Scholar
  32. 32.
    Black EM, Antoci V, Lee TJ et al (2013) Role of preoperative computed tomography cans in operative planning for malleolar ankle fractures. Foot Ankle Int 34(5):697–704CrossRefPubMedGoogle Scholar
  33. 33.
    Meijer DT, de Muinck Keizer RJ, Doornberg JN, Ankle Platform Study Collaborative—Science of Variation Group, et al (2016) Diagnostic accuracy of 2-dimensional computed tomography for articular involvement and fracture pattern of posterior malleolar fractures. Foot Ankle Int 37(1):75–82CrossRefPubMedGoogle Scholar
  34. 34.
    Meijer DT, Doornberg JN, Sierevelt IN, Ankle Platform Study Collaborative—Science of Variation Group;Ankle Platform Study Collaborative—Science of Variation Group et al (2015) Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury 46(10):2024–2029CrossRefPubMedGoogle Scholar
  35. 35.
    Mangnus L, Meijer DT, Stufkens SA et al (2015) Posterior malleolar fracture patterns. J Orthop Trauma 29(9):428–435CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryHMC WesteindeThe HagueThe Netherlands
  2. 2.Department of Trauma SurgeryLeiden University Medical CenterLeidenThe Netherlands

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