Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis

Background: Conventionally ankle fractures have been classified using plain radiographs. Because of complex 3-dimensional anatomy and complexity of injuries, plain radiographs may not always be able to clearly depict the complete fracture pattern. There is a paucity of studies regarding the utility of computed tomography (CT) scanning in malleolar ankle fractures (MAFs). Hence, we conducted this study to further understand the role of the CT scan in MAFs. Methods: A prospective study of 56 consecutive malleolar ankle fractures was conducted. In the first evaluation by a team of 3 observers, a management plan was made based on plain radiographs. All patients received a CT scan evaluation with a standard protocol. The second evaluation by the same team included formulating an operative plan based on the CT. Results: In 13 (23.2%) cases, the management plan changed after CT evaluation. In most of the cases, the change in the management plan included an alteration in fixation of the posterior malleolus followed by lateral malleolus in 4 cases. Most of the changes took place in AO 44 type C followed by types B and A. Maximum change was noted in trimalleolar fractures followed by bimalleolar and unimalleolar. The most common morphological characteristic fracture identified on CT scan that was not evident on plain radiography was Chaput fracture in 17 cases. Conclusion: CT scan evaluation of MAFs changed the management plan in a significant number of cases, especially if the fractured fragment included a posterior malleolus, AO type C, and/or if 2 or more malleoli were fractured as noted on plain x rays. Level of Evidence: Level IV, case series.

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Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

Orthopedic Reviews ◽

10.4081/or.2021.8784 ◽

2021 ◽

Vol 13 (1) ◽

Author(s):

Khalil Nasrallah ◽

Bathish Einal ◽

Haim Shtarker

Keyword(s):

Emergency Department ◽

Ankle Fracture ◽

Treatment Options ◽

Malleolar Fracture ◽

Posterior Malleolar Fracture ◽

Posterior Malleolus ◽

Trimalleolar Fractures ◽

Trimalleolar Fracture ◽

Set Up

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.

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Management of Fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint

Journal of Foot and Ankle Surgery Asia Pacific ◽

10.5005/jp-journals-10040-1077 ◽

2017 ◽

Vol 4 (2) ◽

pp. 90-96

Author(s):

Satish R Gawali ◽

Raman O Toshniwal ◽

Shashikant B Kukale, ◽

Pramod V Nirvane,

Keyword(s):

Soft Tissue ◽

Ankle Joint ◽

Open Reduction ◽

Tissue Injury ◽

Soft Tissue Injury ◽

Malleolar Fractures ◽

Posterior Malleolus ◽

Syndesmosis Injury ◽

Fracture Dislocations ◽

Trimalleolar Fracture

ABSTRACT Background Malleolar fractures of ankle are usually complex injuries, as they are associated with significant ligament and soft tissue injury—injury to syndesmosis and injury to medial and lateral collateral ligaments. The open reduction and internal fixation is not feasible until recovery of significant soft tissue injury and subsidence of edema. Malleolar fractures are articular fractures and have associated subluxation and dislocation of talus. The aims of treatment are to restore normal anatomy and provide sufficient stability for early movements. Malleolar fractures more often require open reduction. Our study aimed to know efficacy and outcome of operative management of them. Materials and methods From January 2013 to March 2015, 35 patients with syndesmotic ankle injury and trimalleolar ankle fractures admitted to the Government Medical College, Latur, India, were operated and followed up prospectively. Results Mean age of patients is 35 years (25–60 years). Fracture union was seen radiologically in 3 to 4 months depending on fracture geometry. We achieved good to excellent results of 90%. Conclusion We conclude that malleolar fractures encountered in clinical practice need thorough assessment and meticulous surgical intervention, as they are associated with injury to ligament complex, i.e., ligament is a key structure in the stability of ankle mortise. Abduction and external rotation types of injuries are the most common types to be seen. We achieved stable fixation and performed early mobilization of the ankle joint, which limits the complications of mainly ankle stiffness. Each malleolus has got its inherent associated complications and calls for special attention for identifying associated conditions, such as syndesmotic injury, talus dislocation in posterior malleolar fractures, irreducible ankle dislocation with trimalleolar fracture, and entrapped fibula behind tibia with irreducible dislocation. How to cite this article Gawali SR, Kukale SB, Nirvane PV, Toshniwal RO. Management of Fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):90-96.

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Posteromedial Fracture Fragment of the Posterior Malleolar Fracture: A Closer Look

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00214 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0021

Author(s):

Gavin Heyes ◽

Amir Reza Vosoughi ◽

Malwattage Lara Tania Jayatilaka ◽

Benjamin Fischer ◽

Andrew P Molloy ◽

...

Keyword(s):

Surgical Planning ◽

Injury Pattern ◽

Computed Tomography Scan ◽

Malleolar Fracture ◽

Fracture Fragment ◽

Fracture Patterns ◽

Posterior Malleolus ◽

Trimalleolar Fractures ◽

Ankle Trauma ◽

Tomography Scan

Category: Ankle, Trauma Introduction/Purpose: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim of this study was to investigate the variability of posteromedial fracture fragments in trimalleolar fractures to enable better surgical planning. Methods: In our department, data on all ankle fractures treated surgically are prospectively collected on our internal database. We collated data from August 2014 to October 2018 for this study. All Mason and Molloy type 2B fractures from our database were identified to analyse the preoperative computed tomography scan. The morphology of the fracture fragment was categorized on whether the fracture appeared to be an intraarticular pilon fragment (i.e. caused by impaction of the talus) or an avulsion extraarticular fracture (i.e. caused by the pull of a ligament). The fracture fragment characteristics were analysed for both the posteromedial and posterolateral fragments. Results: The fracture patterns of the posteromedial fragment were investigated in 47 cases (mean age, 46.6; 11 male, 36 female). Morphologically, the fracture could be divided into 2 subtypes, 1) a large pilon type intra-articular fragment (mean of X axis: 32.97 mm, Y: 30.69 mm, Z: 31.74 mm) present in 29 cases with mean Interfragmentary angle of 32.09 and back of tibia angle of 32.66 degrees. This was seen in 25 out of 27 cases with supination injury pattern. 2) A small extra-articular avulsion fragment (mean of X axis: 9.56 mm, Y: 13.22 mm, Z: 11.53 mm) present in 18 cases with mean Interfragmentary angle of 10.97 and back tibia angle of 10.06 degrees. It was seen in 80% of pronation injuries. Conclusion: The posteromedial fragment of posterior malleolus fracture can be morphologically subtyped into an avulsion type and pilon type variants. The avulsion type is more common in pronation injuries, likely the result of the pull of the inter-malleolar ligament, and the pilon type is more common in supination injuries, likely the result of the rotating talus impaction. Due to the intra-articular involvement, the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type whose function is only a secondary syndesmotic stabiliser.

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The outcome of a single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00379 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0037

Author(s):

Yoo Jung Park ◽

Yougun Won

Keyword(s):

Range Of Motion ◽

Ankle Joint ◽

Screw Fixation ◽

Cannulated Screw ◽

Medial Malleolus ◽

Posterior Malleolus ◽

Significant Difference ◽

Group 2 ◽

Group 1

Category: Trauma Introduction/Purpose: Posterior malleolus fractures occur most commonly in the setting of a rotational ankle fracture. In the treatment of posterior malleolus fractures, the indications for the surgical procedure are determined by the size of the fragment and the articular congruity of the tibiotalar joint. In general, the size of the bone fragment is known to be an indication of surgery if it involves more than 25% of the joint surface, and if it is less than that, anatomical reduction and fixation of only lateral or medial malleolus was suggested. We evaluate the clinical and radiological results of fixation and early range of motion exercise using a single cannulated screw when the fragment of the posterior malleolus fracture is less than 25%. Methods: Among 60 patients with SER stage 3 or 4 who had undergone surgery from March 2010 to March 2014, percutaneous cannulated screw fixation was performed for posterior malleolus in 30 cases (Group 1). In the other 30 cases (Group 2), we did not perform the fixation for posterior malleolus fracture and only cast immobilization was done after fixation for lateral or medial malleolus. Mean follow-up period was 14.8 weeks(12~18) for the Group 1, 12.9 weeks(12~18) for Group 2. Mean age of patients was 46.6(19~78) for Group 1, 50.2(19~74) for Group 2. The range of motion was checked at week 2, 4, 12, and at last follow-up. Results: There was no significant difference of time to union and union rate between two groups, and AOFAS score between two groups also showed no significant difference(91.94(83~100) vs 90.8(85~100), p = 0.45). The range of motion of ankle joint at the final follow-up showed significant difference (Ankle ROM 52.7’ (45’~65’) vs 45.3’(35’~65’), (p<0.01) and complications between two groups also showed no significant difference. Conclusion: A single percutaneous cannulated screw fixation in posterior malleolus fracture accompanied by medial or lateral malleolus fracture can be performed in fractures with small fragment size and minimal displacement. We found that it can be a effective method to achieve early and wide range of motion of ankle joint after posterior mallolus fracture.

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