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Posterior malleolar fractures of the ankle

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Abstract

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

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References

  1. Adams R. Ankle Joint, Abnormal conditions. In: Todd RB (ed). The Cyclopaedia of Anatomy and Physiology of Man. Vol. II. London: Longman; 1835–1836:154–164.

  2. Amorosa LF, Brown GD, Greisberg J. A surgical approach to posterior pilon fractures. J Orthop Trauma. 2010;24:188–93.

    Article  PubMed  Google Scholar 

  3. Ashhurst APC, Bromer RS. Classification and mechanism of fractures of the leg bones involving the ankle. Arch Surg. 1922;4:51–129.

    Article  Google Scholar 

  4. Bartoníček J. Syndesmosis tibiofibularis. [Syndesmosis tibiofibularis. Part II. Contribution of a Clinical Anatomist.] Acta Chir Orthop Tramatol Čechoslov. 1982;49: 374–381.

  5. Bartoníček J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat. 2003;25:379–86.

    Article  PubMed  Google Scholar 

  6. Bartoníček J. Avulsed posterior edge of tibia Earle´s or Volkmann´s triangle? J Bone Joint Surg. 2004;86:746–50.

    Article  Google Scholar 

  7. Bartoníček J, Mittlmeier T, Rammelt S. Anatomie, Biomechanik und Pathomechanik des Pilon tibiale. Fuss Sprung. 2012;10:3–11.

    Article  Google Scholar 

  8. Bartoníček J, Kostlivý K. The history of fractures of the posterior lip of the tibia in fracture-dislocations of the ankle. Ortopedie. 2014;8:132–6.

    Google Scholar 

  9. Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135:506–16.

    Google Scholar 

  10. Bois AJ, Dust W. Posterior fracture dislocation of the ankle: technique and clinical experience using a posteromedial surgical approach. J Orthop Trauma. 2008;22:629–36.

    Article  PubMed  Google Scholar 

  11. Büchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma. 2009;23:208–12.

    Article  PubMed  Google Scholar 

  12. Cotton FJ. A new type of ankle fracture. Am J Med Assoc. 1915;64:318–21.

    Article  Google Scholar 

  13. Chaput V. Les fractures malléolaires du cou-de-pieds et les accidents du travail. Paris: Masson; 1907.

    Google Scholar 

  14. Chen DW, Bing L, Yang YF, Yu GR. Posterior pilon fractures. Foot Ankle Int. 2013;34:766–7.

    Article  CAS  PubMed  Google Scholar 

  15. Cronier P, Steiger V, Rammelt S. Early open reduction and internal fixation of pilon fractures. Fuss Sprungg. 2012;10:12–26.

    Article  Google Scholar 

  16. Destot E. Traumatisme du pied et rayons X. Paris: Masson; 1911.

    Google Scholar 

  17. DeVries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg. 2005;44:211–7.

    Article  CAS  Google Scholar 

  18. Earle H. Simple, succeeded by compound dislocation forwards, of the inferior extremity of the tibia, with fracture of its posterior edge, comminuted fracture of the fibula, amputation of the leg, and death. Lancet. 1828;29(II/6):346–8.

    Google Scholar 

  19. Felsenreich F. Untersuchung über die Pathologie des sogenannten Volkmannschen Dreiecks neben Richtlinien moderner Behandlung schwerer Luxationsfrakturen des oberen Sprunggelenkes. Arch Orthop Unfall-Chir. 1931;29:491–529.

    Article  Google Scholar 

  20. Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8:328–31.

    Article  CAS  PubMed  Google Scholar 

  21. Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma. 2004;18:271–8.

    Article  PubMed  Google Scholar 

  22. Friedburg H, Hendrich V, Wimmer B, Riede UN. Computertomographie bei komplexen Sprunggelenksfrakturen. Radiologie. 1983;23:421–5.

    CAS  Google Scholar 

  23. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Rel Res. 2006;447:165–71.

    Article  Google Scholar 

  24. Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE. Surgeon practices regarding operative tretment of posterior malleolus fractures. Foot Ankle Int. 2011;32:385–93.

    Article  PubMed  Google Scholar 

  25. Grondahl NB. Fractura marginalis posterior tibiae og andre bruddkomplikationer ved ankelbrudd. Norsk Mag F Laegevidensk. 1913;11:737.

    Google Scholar 

  26. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg. 2006;88-A:1085–92.

    Article  Google Scholar 

  27. Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg. 1988;70-A:1348–56.

    Google Scholar 

  28. Harper MC. Talar shift. The stabilizing role of the medial, lateral, and posterior ankle structures. Clin Orthop Relat Res. 1990;257:177–83.

    PubMed  Google Scholar 

  29. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area Contribution of posterior malleolus and deltoid ligament. Clin Orthop Rel Res. 1995;20:182–7.

    Google Scholar 

  30. Heim U. Indikation und Technik der Stabilisierung des hinteren Kantendreiecks nach Volkmann bei Malleolarfrakturen. Unfallheilkunde. 1982;85:388–94.

    CAS  PubMed  Google Scholar 

  31. Heim UFA. Trimalleoar fractures: late results after fixation of the posterior fragment. Orthopedics. 1989;12:1053–9.

    CAS  PubMed  Google Scholar 

  32. Heim D, Niederhauser K, Simbray N. The Volkmann dogma: a retrospective, long-term, single-center study. Eur J Trauma Emerg Surg. 2010;36:515–9.

    Article  Google Scholar 

  33. Heim D. posterior Malleolus bzw. Das Volkmann-Dreieck. Unfallchirurg. 2013;116:781–8.

    CAS  Google Scholar 

  34. Henderson MS. Trimalleolar fractures of the ankle. Surg Clin N Am. 1932;12:867–72.

    Google Scholar 

  35. Hinds RM, Garner MR, Lazaro LE, Warner SJ, Loftus ML, Birnbaum JF, Burket JC, Lorich DG. Ankle fracture spur sign is pathognomic for a variant ankle fracture. Foot Ankle Int. 2015;36:159–64.

    Article  PubMed  Google Scholar 

  36. Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013;21:32–40.

    Article  PubMed  Google Scholar 

  37. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565–70.

    Article  CAS  PubMed  Google Scholar 

  38. Jehlička D, Bartoníček J, Svatoš F, Dobiáš J. Fracture-dislocations of the ankle in adults. Part I: epidemiological evaluation of one-year group of patients. Acta Chir Orthop Tramatol Čech. 2002;69:243–7.

    Google Scholar 

  39. Karachalios T, Roidis N, Karoutis D, Bargiotas K, Karachalios GG. Trimalleolar fracture with a double fragment of the posterior malleolus: a case report and modified operative approach to internal fixation. Foot Ankl Int. 2001;22:144–9.

    CAS  Google Scholar 

  40. Kim MB, Lee YH, Kim JH, Lee JE, Baek GH. Lateral transmalleolar approach and miniscrews fixation for displaced posterolateral fragments of posterior malleolus fractures in adults: a consecutive study. J Orthop Trauma. 2015;29:105–11.

    Article  PubMed  Google Scholar 

  41. Klammer G, Kadakia AR, Joos DA, Seybld JD, Espinosa N. Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankl Int. 2013;34:189–99.

    Article  Google Scholar 

  42. Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RMJM. Results of ankle fractures with involvement oft he posterior tibial margin. J Trauma. 2002;53:55–60.

    Article  PubMed  Google Scholar 

  43. Lauge N. Fractures of the ankle. Arch Surg. 1948;56:259–317.

    Article  CAS  PubMed  Google Scholar 

  44. Lauge-Hansen N. Fractures of the ankle. Part 2. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957–87.

    Article  CAS  PubMed  Google Scholar 

  45. Leed HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg. 1984;66-A:490–503.

    Google Scholar 

  46. Leveuf J. Traitment des fractures et luxations des membres. Paris: Masson; 1925.

    Google Scholar 

  47. Lindsjø U. Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res. 1985;199:28–38.

    PubMed  Google Scholar 

  48. Lounsbury BF, Metz AR. Lipping fracture of lower articular end of tibia. Arch Surg. 1922;5:678–90.

    Article  Google Scholar 

  49. Ludloff K. Zur Frage der Knöchelbrüche mit Herausprengung eines hinteren Volkmann´schen Dreiecks. Zentralbl Chir. 1926;53:390–1.

    Google Scholar 

  50. Macko VW, Matthews IS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle The contribution of posterior malleolus. J Bone Joint Surg. 1991;73A:347–51.

    Google Scholar 

  51. Magid D, Michelson JD, Ney DR, Fishman EK. Adult ankle fractures: comparison of plain films and interactive two- and three dimensional CT scans. Am J Radiol. 1990;154:1017–23.

    CAS  Google Scholar 

  52. McKinley TO, Rudert MJ, Koos DC, Brown TD. Incongruity versus instability in the etiology of posttraumatic arthritis. Clin Orthop Relas Res. 2004;423:44–51.

    Article  Google Scholar 

  53. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010;468:1129–35.

    Article  PubMed Central  PubMed  Google Scholar 

  54. Müller ME, Allgöver M, Willeneger H (Hrgs). Technik der operativen Frakturbehandlung. Berlin, Springer 1963:123–124.

  55. Müller ME, Allgöwer M, Schneider R, Willneger H (Hrgs). Manual der Osteosynthese. 3. Aufl. Berlin; Springer 1991:595–612.

  56. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of long bones. Berlin: Springer; 1987.

    Google Scholar 

  57. Nelson MC, Jensen NK. The treatment of trimalleolar fractures of the ankle. Surg Gynec Obst. 1940;71:509–14.

    Google Scholar 

  58. O’Connor TJ, Mueller B, Ly TV, Jacobson AR, Nelson ER, Cole PA. A to P” screw vs posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015;29:e151–6.

    Article  PubMed  Google Scholar 

  59. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I. Anatomical studies. Acta Orthop Scand. 1979;50:217–23.

    Article  CAS  PubMed  Google Scholar 

  60. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. II. Clinical studies. Acta Orthop Scand. 1979;50:223–36.

    Google Scholar 

  61. Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E. Early weightbearing after posterior malleolus: an experimental and prospective clinical study. J Foot Ankle Surg. 2003;42:99–104.

    Article  PubMed  Google Scholar 

  62. Raasch WG, Larkin JJ, Draganich LF. Assessment of the posterior malleolus as a restraint to posterior subluxation of the ankle. J Bone Joint Surg. 1992;74:1201–6.

    CAS  PubMed  Google Scholar 

  63. Rammelt S, Zwipp H, Grass R. Ankle fractures: operative technique. Unfallchirurg. 2008;111:439–47.

    Article  CAS  PubMed  Google Scholar 

  64. Rammelt S, Heim D, Hofbauer LC, Grass R, Zwipp H. Problems and controversies in the treatment of ankle fractures. Unfallchirurg. 2011;114:847–60.

    Article  CAS  PubMed  Google Scholar 

  65. Rammelt S, Zwipp H, Mittlmeier T. Operative treatment of pronation fracture-dislocations of the ankle. Oper Orthop Traumatol. 2013;25:273–93.

    Article  CAS  PubMed  Google Scholar 

  66. Rammelt S, Marti RK, Zwipp H. Joint-preserving osteotomy of malunited ankle and pilon fractures. Unfallchirurg. 2013;16:789–96.

    Article  Google Scholar 

  67. Souligoux. Des fractures du cou-de-pied. Tribune Med 1913;47:1.

  68. Streubel PN, McCormick JJ, Gardner MJ. The posterior malleolus: should it be fixed and why? Curr Orthop Prax. 2011;22:17–24.

    Article  Google Scholar 

  69. Switaj PJ, Weatherford B, Fuchs D, Rosenthal B, Pang E, Kadakia AR. Evaluation of posterior malleolar fractures and the posterior pilon in operatively treated ankle fractures. Foot Ankl Int. 2014;35:886–95.

    Article  Google Scholar 

  70. Tejwani NC, Pahk B, Egol AE. Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma. 2010;69:666–9.

    Article  PubMed  Google Scholar 

  71. Trojan E. Die Behandlung der Knöchelbrüche mit Abscherung eines grossen hinteren Schienbeinkeiles. Z Orthop. 1953;84:636–44.

    Google Scholar 

  72. van den Bekerom MPJ, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009;66:279–84.

    Article  PubMed  Google Scholar 

  73. Volkmann R, Volkmann R. Beiträge zur Chirurgie anschliessend an einen Bericht über die Thätigkeit der chirurgischen: Universitätsklinik zu Halle im Jahre 1873. Leipzig: Breitkopf und Härtel; 1875. p. 104–9.

    Google Scholar 

  74. Vrahas M, Fu F, Veenis B. Intraarticular contact stresses with simulated ankle malunions. J Orthop Trauma. 1994;8:159–66.

    Article  CAS  PubMed  Google Scholar 

  75. Weber BG. Die Verletzungen des oberen Sprunggelenkes. Bern: Huber; 1966.

    Google Scholar 

  76. Weber M, Ganz R. Malunion following trimalleolat fracture with posterolateral subluxation oft he talus—reconstruction including the posterior malleolus. Foot Ankl Int. 2003;24:338–44.

    Google Scholar 

  77. Weber M. Trimalleolar fractures with impaction oft the posteromedial tibial plafond: implications for talar stability. Foot Ankle Int. 2004;25:716–27.

    PubMed  Google Scholar 

  78. Xu H, Zhang D, Fu Z, Wang T, Zhang P, Jiang B, Shen H, Wang G, Wang G, Wu X. A retrospective study of posterior malleolus fractures. Int Orthop. 2012;36:1929–36.

    Article  PubMed Central  PubMed  Google Scholar 

  79. Yao L, Zhang W, Yang G, Zhu Y, Zhai Q, Luo C. Morphologic characteristics of the posterior malleolar fragment: a 3-D computer tomography based study. Arch Orthop Trauma Surg. 2014;134:389–94.

    Article  PubMed  Google Scholar 

  80. Zenker H. Nerlich M Prognostic aspects in operated ankle fractures. Arch Orthop Trauma Surg. 1982;100:237–41.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, U Vojenské nemocnice 1200, 169 02, Prague 6, Czech Republic

    J. Bartoníček & M. Tuček

  2. Department of Anatomy, First Faculty of Medicine, Charles University Prague, U nemocnice 3, 120 00, Prague 2, Czech Republic

    J. Bartoníček & O. Naňka

  3. University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany

    S. Rammelt

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Jan Bartoníček, Stefan Rammelt, Michal Tuček and Ondřej Naňka declare that they have no conflict of interest.

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

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