Skip to main content

Advertisement

SpringerLink
Log in

Ankle CT scan allows better management of posterior malleolus fractures than X-rays

  • Original Article
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

A Correction to this article was published on 05 October 2021

This article has been updated

Abstract

Purpose

Undiagnosed and undertreated posterior malleolus fractures lead to early ankle instability and arthritis. A preoperative CT scan could improve the management of those fractures. This study assessed the benefits of a systematic ankle CT scanner to diagnose and manage posterior malleolus fracture.

Methods

A monocentric retrospective cohort study was conducted. Sixty consecutive patients with bimalleolar fractures were operated and underwent a preoperative CT scan. The mean age was 50.0 years old (18.6 years old) with a mean body mass index of 20.3 (kg/m2) (11.4 kg/m2) and 71.7% (43/60) of women. The primary outcome was the rate of posterior malleolus fragment diagnosed on X-rays and on CT scan. Secondly, interobserver and interobserver’s agreement were compared between conventional X-rays and CT scan.

Results

Thirty-five (58.3%) posterior fragment fractures were observed on X-rays and 53 (88.3%) on the preoperative CT scan (p < 0.01). The intraobserver reproducibility for X-rays was low (0.02 [− 0.23; 0.27]) and moderate for CT scan (0.45 [0.0; 0.84]). The interobserver reproducibility for X-rays was moderate (0.39 [0.15; 0.60]) and excellent for CT scan (0.78 [0.0; 1.0]).

Conclusion

A wide proportion of bimalleolar fractures are associated with posterior malleolus fractures and undiagnosed with standard X-rays. We advocate a systematic preoperative CT scan in the management of bimalleolar fractures.

Level of evidence

Level IV, retrospective cohort study.

Trial registration number

2218999v0, date of registration: 11/08/2020 (retrospectively registered).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Availability of data and material

Available on request.

Code availability

Available on request.

Change history

References

  1. Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury 37:691–697. https://doi.org/10.1016/j.injury.2006.04.130

    Article  PubMed  Google Scholar 

  2. Thordarson DB, Motamed S, Hedman T et al (1997) The effect of fibular malreduction on contact pressures in an ankle fracture malunion model*. JBJS 79:1809–1815

    Article  CAS  Google Scholar 

  3. Rukavina A (1998) The role of fibular length and the width of the ankle mortise in post-traumatic osteoarthrosis after malleolar fracture. Int Orthop 22:357–360. https://doi.org/10.1007/s002640050277

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Wei SY, Okereke E, Winiarsky R, Lotke PA (1999) Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20-year follow-up. Foot Ankle Int 20:404–407. https://doi.org/10.1177/107110079902000702

    Article  CAS  PubMed  Google Scholar 

  5. Mosca M, Caravelli S, Fuiano M et al (2020) Management of early ankle osteoarthritis through anterior joint-preserving surgery: a retrospective evaluation at mid- to long-term follow-up. Eur J Orthop Surg Traumatol 30:1171–1178. https://doi.org/10.1007/s00590-020-02691-6

    Article  PubMed  Google Scholar 

  6. Blom RP, Hayat B, Al-Dirini RMA, et al (2020) Posterior malleolar ankle fractures. Bone Joint J 102:1229–1241

  7. Gandham S, Millward G, Molloy AP, Mason LW (2020) Posterior malleolar fractures: a CT guided incision analysis. Foot (Edinb) 43:101662. https://doi.org/10.1016/j.foot.2019.101662

    Article  Google Scholar 

  8. Jeyaseelan L, Bua N, Parker L et al (2020) Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury. https://doi.org/10.1016/j.injury.2020.12.006

    Article  PubMed  Google Scholar 

  9. Rammelt S, Bartoníček J (2020) Posterior malleolar fractures: a critical analysis review. JBJS Rev 8(e19):00207. https://doi.org/10.2106/JBJS.RVW.19.00207

    Article  PubMed  Google Scholar 

  10. Yang Y, He W, Zhou H et al (2020) Combined posteromedial and posterolateral approaches for 2-part posterior malleolar fracture fixation. Foot Ankle Int 41:1234–1239. https://doi.org/10.1177/1071100720937637

    Article  PubMed  Google Scholar 

  11. Bartoníček J, Rammelt S, Tuček M (2017) Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 22:125–145. https://doi.org/10.1016/j.fcl.2016.09.009

    Article  PubMed  Google Scholar 

  12. Fort NM, Aiyer AA, Kaplan JR et al (2017) Management of acute injuries of the tibiofibular syndesmosis. Eur J Orthop Surg Traumatol 27:449–459. https://doi.org/10.1007/s00590-017-1956-2

    Article  PubMed  Google Scholar 

  13. Kannus P, Palvanen M, Niemi S et al (2002) Increasing number and incidence of low-trauma ankle fractures in elderly people: finnish statistics during 1970–2000 and projections for the future. Bone 31:430–433. https://doi.org/10.1016/s8756-3282(02)00832-3

    Article  CAS  PubMed  Google Scholar 

  14. Ferries JS, DeCoster TA, Firoozbakhsh KK et al (1994) Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma 8:328–331. https://doi.org/10.1097/00005131-199408000-00009

    Article  CAS  PubMed  Google Scholar 

  15. Büchler L, Tannast M, Bonel HM, Weber M (2009) Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma 23:208–212. https://doi.org/10.1097/BOT.0b013e31819b0b23

    Article  PubMed  Google Scholar 

  16. Magid D, Michelson JD, Ney DR, Fishman EK (1990) Adult ankle fractures: comparison of plain films and interactive two- and three-dimensional CT scans. Am J Roentgenol 154:1017–1023. https://doi.org/10.2214/ajr.154.5.2108536

    Article  CAS  Google Scholar 

  17. Meijer DT, Gevers Deynoot BDJ, Stufkens SA et al (2019) What factors are associated with outcomes scores after surgical treatment of ankle fractures with a posterior malleolar fragment? Clin Orthopaed Related Res 477:863–869

  18. Weber BG (1972) Die Verletzungen des oberen Sprunggelenkes. Huber, Bern

    Google Scholar 

  19. Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 58:356–357

    Article  CAS  Google Scholar 

  20. Black EM, Antoci V, Lee JT et al (2013) Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int 34:697–704. https://doi.org/10.1177/1071100713475355

    Article  PubMed  Google Scholar 

  21. Bartoníček J, Rammelt S, Tuček M, Naňka O (2015) Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg 41:587–600. https://doi.org/10.1007/s00068-015-0560-6

    Article  PubMed  Google Scholar 

  22. Testa G, Ganci M, Amico M et al (2019) Negative prognostic factors in surgical treatment for trimalleolar fractures. Eur J Orthop Surg Traumatol 29:1325–1330. https://doi.org/10.1007/s00590-019-02430-6

    Article  PubMed  Google Scholar 

  23. Solan MC, Sakellariou A (2017) Posterior malleolus fractures. Bone Joint J 99:1413–1419

  24. Odak S, Ahluwalia R, Unnikrishnan P et al (2016) Management of posterior malleolar fractures: a systematic review. J Foot Ankle Surg 55:140–145. https://doi.org/10.1053/j.jfas.2015.04.001

    Article  PubMed  Google Scholar 

  25. Scheinfeld MH, Dym AA, Spektor M et al (2015) Acetabular fractures: what radiologists should know and how 3D CT can aid classification. Radiographics 35:555–577. https://doi.org/10.1148/rg.352140098

    Article  PubMed  Google Scholar 

  26. Xie X, Zhan Y, Dong M et al (2017) Two and three-dimensional CT mapping of hoffa fractures. J Bone Joint Surg Am 99:1866–1874. https://doi.org/10.2106/JBJS.17.00473

    Article  PubMed  Google Scholar 

  27. Millán-Billi A, Gómez-Masdeu M, Ramírez-Bermejo E et al (2017) What is the most reproducible classification system to assess tibial plateau fractures? Int Orthop 41:1251–1256. https://doi.org/10.1007/s00264-017-3462-x

    Article  PubMed  Google Scholar 

  28. Cole PA, Mehrle RK, Bhandari M, Zlowodzki M (2013) The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma 27:e152-156. https://doi.org/10.1097/BOT.0b013e318288a7e9

    Article  PubMed  Google Scholar 

  29. Sanders R, Vaupel ZM, Erdogan M, Downes K (2014) Operative treatment of displaced intraarticular calcaneal fractures: long-term (10–20 Years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma 28:551–563. https://doi.org/10.1097/BOT.0000000000000169

    Article  PubMed  Google Scholar 

  30. Kumar A, Mishra P, Tandon A et al (2018) Effect of CT on Management plan in malleolar ankle fractures. Foot Ankle Int 39:59–66. https://doi.org/10.1177/1071100717732746

    Article  PubMed  Google Scholar 

  31. Leung KH, Fang CX, Lau TW, Leung FK (2016) Preoperative radiography versus computed tomography for surgical planning for ankle fractures. J Orthop Surg (Hong Kong) 24:158–162. https://doi.org/10.1177/1602400207

    Article  CAS  Google Scholar 

  32. Meijer DT, de Muinck K-JO, Doornberg JN et al (2016) Diagnostic accuracy of 2-dimensional computed tomography for articular involvement and fracture pattern of posterior malleolar fractures. Foot Ankle Int 37:75–82. https://doi.org/10.1177/1071100715603999

    Article  PubMed  Google Scholar 

  33. Meijer DT, Doornberg JN, Sierevelt IN et al (2015) Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury 46:2024–2029. https://doi.org/10.1016/j.injury.2015.07.019

    Article  CAS  PubMed  Google Scholar 

  34. Sheikh HQ, Mills EJ, McGregor-Riley JC et al (2020) The effect of computerised tomography on operative planning in posterior malleolus ankle fractures. Foot Ankle Surg 26:676–680. https://doi.org/10.1016/j.fas.2019.08.007

    Article  PubMed  Google Scholar 

  35. Szymański T, Zdanowicz U (2021) Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures—How much do we miss? Foot Ankle Surg. https://doi.org/10.1016/j.fas.2021.03.025

    Article  PubMed  Google Scholar 

  36. Court-Brown CM, McBirnie J, Wilson G (1998) Adult ankle fractures–an increasing problem? Acta Orthop Scand 69:43–47. https://doi.org/10.3109/17453679809002355

    Article  CAS  PubMed  Google Scholar 

  37. Bengnér U, Johnell O, Redlund-Johnell I (1986) Epidemiology of ankle fracture 1950 and 1980. Increasing incidence in elderly women. Acta Orthop Scand 57:35–37. https://doi.org/10.3109/17453678608993211

    Article  PubMed  Google Scholar 

Download references

Funding

No specific funding.

Author information

Authors and Affiliations

  1. Orthopaedic Department, Cochin University Hospital, APHP Paris, Paris Descartes University, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France

    Pierre-Alban Bouche, Nicolas Gaujac, Simon Corsia & Philippe Anract

  2. Orthopaedic Department, Croix St Simon Hospital, 125 rue d’Avron, 75020, Paris, France

    Philippe Leclerc & Guillaume Auberger

Authors
  1. Pierre-Alban Bouche
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nicolas Gaujac
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Simon Corsia
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Philippe Leclerc
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Philippe Anract
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Guillaume Auberger
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

P-AB designed the article, analyzed the data and wrote the article. NG was involved in data collection and proofreading the article. SC contributed to article writing and proofreading the article. PL designed and proofread the article. PA designed and proofread the article. GA designed and proofread the article and analyzed the data.

Corresponding author

Correspondence to Pierre-Alban Bouche.

Ethics declarations

Conflict of interest

The author(s) declare that they have no competing interests.

Ethical approval

This study was approved by the Commission Nationale Informatique et Libertés (CNIL, https://www.cnil.fr) under the MR-003 reference N° 2218999v0.

Consent to participate

All patients were informed about the study.

Consent for publication

All named authors have read the manuscript and agreed to its submission.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bouche, PA., Gaujac, N., Corsia, S. et al. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. Eur J Orthop Surg Traumatol 32, 1301–1309 (2022). https://doi.org/10.1007/s00590-021-03104-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-021-03104-y

Keywords

Search

Navigation