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

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.

scholarly journals Screw Fixation of the Posterior Malleolus Fragment in Ankle Fracture: Cadaveric and Clinical Studies

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0026
Author(s):  
Gisoo Lee ◽  
Chan Kang ◽  
Yougun Won ◽  
Jae Hwang Song ◽  
Byungki Cho
Keyword(s):  
Clinical Outcomes ◽  
Ankle Fracture ◽  
Screw Fixation ◽  
Articular Surface ◽  
Cannulated Screw ◽  
Ankle Fractures ◽  
Neutral Position ◽  
Early Recovery ◽  
Malleolar Fracture ◽  
Posterior Malleolus

Category: Ankle, Trauma Introduction/Purpose: Previously, a posterior malleolus fragment (PMF) covering 25–30% of the articular surface was a known indication for surgical fixation for ankle fractures. This study aimed to compare the outcomes of screw fixation for PMF comprising <25% of the articular surface and to evaluate the results of cadaver experiments. Methods: The clinical study enrolled ankle fracture patients with PMFs who planned to undergo surgery between March 2014 and February 2017. Among them, 62 with type 1 PMF comprising <25% of the articular surface were included: 32 patients underwent cannulated screw fixation for PMF after fixation for lateral and/or medial malleolar fracture (A group), whereas the other 30 patients underwent internal fixation for lateral and/or medial malleolar fracture but no screw fixation (B group). Clinical outcomes were determined at the 3-, 6-, 12-, and 18-month visits. Additionally, cadaver studies were conducted to evaluate cannulated screw fixation or no fixation in cases of PMFs comprising <25% of the articular surface and >1 mm displacement. Ankle joint stability was measured under external torque on the ankle in the neutral position. The level of significance was set at P < .05. Results: Clinical outcomes at 6 and 12 months after surgery were significantly higher in group A than in group B. However, there was no significant intergroup difference in clinical outcomes at 18 months of follow-up. In the cadaver study, PMF screw fixations were significantly more stable under external rotation force. Conclusion: Screw fixation was significantly useful during early recovery and in short-term clinical outcomes owing to stabilization of ankle fractures with PMF involving <25% of the articular surface.

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

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.

scholarly journals Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0034
Author(s):  
Lyndon Mason ◽  
Lara Jayatilaka ◽  
Andrew Fisher ◽  
Lauren Fisher ◽  
Andrew Molloy
Keyword(s):  
Lower Limbs ◽  
Human Anatomy ◽  
Tibialis Posterior ◽  
Ligamentous Injury ◽  
Malleolar Fracture ◽  
Malleolar Fractures ◽  
Tibiofibular Ligament ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus

Category: Ankle Introduction/Purpose: The treatment of posterior malleolar fractures is developing. Our previous study on the anatomy of the posterior malleolar fracture identified only 49% of rotational push off fractures of the posterior malleolus had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament insertion on the posterior tibia and its relation to push off fractures. Methods: We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. Results: In all specimens, the tibial insertion of the PITFL encompassed 1/3 of the distal posterior tibia. In addition, the posterior intermalleolar ligament inserted onto the posterior tibia just medial to the tibialis posterior groove. Thus a rotational push off fracture would only cause syndesmotic injury if greater than a 3 rd of the posterior tibia was injured or occurred in combination with a ligamentous injury. This is in keeping with the clinical findings of only 49% syndesmotic instabilities with Haraguchi type 1 posterior malleolar fractures. Conclusion: Haraguchi type 1 posterior malleolar fractures (less than a 3 rd of the width of the posterior tibia) are unlikely to cause syndesmotic instabilities without the addition of a ligamentous injury.

scholarly journals The Lateral Trans-Malleolar approach for Posterior Malleolar Fracture of the Ankle: A Clinical and Computed Tomography Evaluation

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0046
Author(s):  
Masanori Taki ◽  
Naohiro Hio
Keyword(s):  
Computed Tomography ◽  
External Rotation ◽  
Articular Surface ◽  
Clinical Results ◽  
Direct Visualization ◽  
Malleolar Fracture ◽  
Aofas Score ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus

Category: Ankle; Trauma Introduction/Purpose: Posterior malleolar fracture reduction including the articular surface of trimalleolar ankle fracture has been reported to be an important prognostic factor. The lateral trans-malleolar approach (LTA) is a surgical approach that provides direct visualization of the articular surface of the posterior malleolus. We herein report the clinical results and computed tomography (CT) findings for the articular reduction status after LTA for posterior malleolar fracture of the ankle. Methods: Sixteen patients (9 men, 7 women, mean age 52.6+-18.1 years old) who underwent the LTA for posterior malleolar fracture of the ankle and were followed for at least 1 year were evaluated retrospectively. The types of ankle malleolar fracture according to the Lauge-Hansen classification were Supination-External rotation (SER) in 13 patients and Pronation-External rotation (PER) in 3 patients. The CT classifications of posterior malleolus fracture by Haraguchi were Type 1 in 6 cases, Type 2 in 10 cases and Type 3 in 0 cases. The AOFAS score, post-surgical complications and reduction status of the posterior malleolus on CT were investigated. Results: The mean follow-up period was 15.5 months. The AOFAS score was 93.0+-5.2 points. Postoperative complications were seen in one case of superficial infection; however, delayed union, nonunion and fibular necrosis were not observed. The articular step-off in CT improved significantly after surgery (5.9+-2.9 mm preoperatively vs. 0.6+-0.8 mm postoperatively). The 2 patients who showed an articular step-off exceeding 1 mm were both Haraguchi type 2 posterior malleolar fracture. Conclusion: Several approaches for managing posterior malleolus of the ankle have been reported. However, few provide direct visualization to the articular surface. The LTA requires relatively substantial invasion, but it can facilitate surgery in the supine position and thereby reduce the articular surface directly. In our experience, the LTA provided favorable clinical results and fracture reductions. Even when utilizing the LTA, it remains difficult to confirm the fracture reduction of medial articular surface for Haraguchi type 2 medial extension fractures. Therefore, it remains important to also perform appropriate intraoperative X-ray controls.

scholarly journals Early Weightbearing After Operatively Treated Trimalleolar Ankle Fractures with Large Posterior Malleolar Fragments

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0047
Author(s):  
Jason Tartaglione ◽  
Sorawut Thamyongkit ◽  
Pooyan Abbasi ◽  
Brent Parks ◽  
Erik Hasenboehler ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Ankle Fractures ◽  
Malleolar Fracture ◽  
Fracture Displacement ◽  
Posterior Malleolar Fracture ◽  
Average Motion ◽  
Significant Difference ◽  
Surgical Fixation ◽  
Group 2 ◽  
Group 1

Category: Trauma Introduction/Purpose: No consensus exists regarding postoperative rehabilitation protocols after surgical fixation of unstable trimalleolar ankle fractures with large posterior malleolar fragments. Additionally, no consensus exists regarding type of fixation of large posterior malleolar fragments in these fractures. It is unclear whether clinical results with early weightbearing differ between large posterior malleolar fragments fixed with either screws alone or a plate and screws construct. We evaluated fracture displacement with simulated early weightbearing in a cadaveric model. Methods: Sixteen fresh-frozen lower extremities were assigned to Group 1, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with screws (n=8) or Group 2, trimalleolar ankle fracture with a large posterior malleolar fragment fixed with a plate and screws construct (n=8). Both Groups were tested with an axial compressive load at 3.2 Hz from 100 to 1,000 N and internal/external torque at 1.6 Hz at 0.5 Nm for 250,000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. Results: The average motion at all fracture sites in both groups was less than 1 mm. Group 1 displacement of the medial, lateral, and posterior malleolar fracture was 0.30 ± 0.27 mm, 0.12 ± 0.11 mm, and 0.87 ± 0.68 mm respectively. Group 2 displacement of the medial, lateral, and posterior malleolar fracture was 0.78 ± 1.52 mm, 0.12 ± 0.16 mm, and 0.87 ± 1.20 mm respectively. There was no significant difference between the average motion at all fractures sites between Group 1 and Group 2 (P > 0.05). There was no statistical correlation between fracture displacement and bone mineral density. Conclusion: This study supports early weightbearing after surgical fixation of unstable trimalleolar ankle fractures regardless of type of fixation of the posterior malleolus. Further investigation of early weightbearing protocols after surgical fixation of unstable trimalleolar ankle fractures are needed to help guide future treatment.

Anatomy of the Insertion of the Posterior Inferior Tibiofibular Ligament and the Posterior Malleolar Fracture

2019 ◽  
Vol 40 (11) ◽  
pp. 1319-1324 ◽  
Author(s):  
Malwattage Lara Tania Jayatilaka ◽  
Matthew D. G. Philpott ◽  
Andrew Fisher ◽  
Lauren Fisher ◽  
Andrew Molloy ◽  
...  
Keyword(s):  
Transverse Component ◽  
Lower Limbs ◽  
Ligamentous Injury ◽  
Malleolar Fracture ◽  
Posterior Aspect ◽  
Tibiofibular Ligament ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Average Size

Background: Our aim in this study was to identify the extent of the posterior inferior tibiofibular ligament (PITFL) insertion on the posterior tibia and its relation to intra-articular posterior malleolar fractures. Methods: Careful dissection was undertaken on 10 cadaveric lower limbs to identify the ligamentous structures on the posterior aspect of the ankle. The ligamentous anatomy was further compared with our ankle fracture database, specifically posterior malleolar fracture patterns, demonstrating a rotational pilon etiology (Mason and Molloy type 2A and B). Computed tomography imaging was used to measure the dimensions of the fracture fragments. Results: The superficial PITFL was found to have a transverse component and an oblique component. The average size of the tibial insertion was 54.9 mm (95% CI, 51.8, 58.0) from joint line and 47.1 mm (95% CI, 43.0, 51.2) transverse. From our database of ankle fractures involving the posterior malleolus, 80 Mason and Molloy type 2 fractures were identified for analysis. Of these, 33 were type 2A and 47 were type 2B. The posterolateral fragments had an average size of 26.3 mm (95% CI, 25.0, 27.7) height and 22.1 mm (95% CI, 21.1, 23.1) width. The posteromedial fragments had an average size of 22.0 (95% CI, 18.9, 25.1) height and 19.8 (95% CI, 17.5, 22.0) width. Conclusion: The superficial PITFL insertion on the tibia is broad. In comparison with the average size of the posterior malleolar fragments, the PITFL insertion is significantly larger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury must also occur. Clinical Relevance: Posterior syndesmotic instability results from injury to the PITFL. It has been widely reported that a posterior malleolar fracture will also give rise to posterior syndesmotic instability due to the insertion of the deep PITFL on the posterior tibia. On the contrary, in this paper, we have shown that the superficial PITFL insertion on the tibia is very large, much greater than the average size of the posterior malleolar fragments. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur.

CT Analysis of the Posteromedial Fragment of the Posterior Malleolar Fracture

2019 ◽  
Vol 40 (6) ◽  
pp. 648-655 ◽  
Author(s):  
Amir Reza Vosoughi ◽  
Malwattage Lara Tania Jayatilaka ◽  
Benjamin Fischer ◽  
Andrew P. Molloy ◽  
Lyndon W. Mason
Keyword(s):  
Computed Tomography ◽  
Surgical Planning ◽  
Injury Pattern ◽  
Computed Tomography Scan ◽  
Malleolar Fracture ◽  
Level Of Evidence ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus ◽  
Ct Analysis ◽  
Tomography Scan

Background: To date, there have been no studies describing the characteristics of posteromedial fragment in the posterior malleolus fracture. The aim was to investigate the variability of posteromedial fracture fragments to enable better surgical planning. Methods: All Mason and Molloy type 2B fractures, defined as fracture of both the posterolateral and the posteromedial fragments of the posterior malleolus, from our database were identified to analyze the preoperative computed tomography scan. The posteromedial fragment was investigated in 47 cases (mean age, 46.6 years; 11 male, 36 female). Results: Morphologically, the fracture could be divided into 2 subtypes: (1) a large pilon intra-articular fragment (mean of X axis: 33.0 mm, Y: 30.7 mm, Z: 31.7 mm) presented in 29 cases with mean interfragmentary angle of 32.1 and back of tibia angle of 32.7 degrees (this was seen in 25 of 27 cases with supination injury pattern); and (2) a small extra-articular avulsion fragment (mean of X axis: 9.6 mm, Y: 13.2 mm, Z: 11.5 mm) present in 18 cases with a mean interfragmentary angle of 11.0 and back of tibia angle of 10.1 degrees. It was seen in 80% of pronation injuries. Conclusion: The avulsion type of the posteromedial fragment of posterior malleolus fracture was more common in pronation injuries, likely the result of traction by the intermalleolar ligament, and the pilon type was more common in supination injuries, likely the result of the rotating talus impaction. Because of the intra-articular involvement, we believe the pilon type should undergo fixation to achieve articular congruity, unlike the avulsion type which may only function as a secondary syndesmotic stabilizer. Level of Evidence: Level III, retrospective comparative series.

scholarly journals Is surgery the only option for unstable ankle fracture?

2020 ◽  
Vol 6 (3) ◽  
pp. 506
Author(s):  
Marikannan C. ◽  
Dorai Kumar R. ◽  
Mohan Choudary B. ◽  
Thirunthaiyan M. R. ◽  
Tarun Prashanth K. R.
Keyword(s):  
Functional Outcome ◽  
Ankle Fracture ◽  
External Rotation ◽  
Aofas Score ◽  
Posterior Malleolus ◽  
Trimalleolar Fractures ◽  
Single Centre Study ◽  
American Orthopaedic ◽  
Displaced Fracture ◽  
Supination External Rotation

<p class="abstract"><strong>Background:</strong> Ankle fracture is one of the most common injuries in sports and daily activity. Unstable ankle fracture that are displaced fracture of the lateral malleolus and most bimalleolar or trimalleolar fractures need surgical reduction and fixation.</p><p class="abstract"><strong>Methods:</strong> It is a single centre study in which all unstable ankle fracture above the age of 18 and not associated with any other injury were included in the study. Following fixation patients were followed up at 6 weeks, 3 months and 6 months and functional outcome was assessed with American Orthopaedic Foot and Ankle score (AOFAS).<strong></strong></p><p class="abstract"><strong>Results:</strong> Supination external rotation injury was most common type. Mean AOFAS score at the end of six months was found to be best in supination adduction type. Posterior malleolus fixation with screw were found to have maximum AOFAS score.</p><p class="abstract"><strong>Conclusions:</strong> Surgical outcome in unstable ankle fracture are proved to have good functional outcome.</p>

scholarly journals PO 18204 - Posterior ankle arthroscopy for percutaneous fixation of a posterior malleolar fracture

2019 ◽  
Vol 13 (Supl 1) ◽  
pp. 44S
Author(s):  
Guilherme De Souza Fernandes ◽  
Claudio Velleca e Silva
Keyword(s):  
Internal Fixation ◽  
External Rotation ◽  
Fracture Dislocation ◽  
Osteochondral Lesions ◽  
Flexor Hallucis Longus ◽  
Percutaneous Fixation ◽  
Malleolar Fracture ◽  
Percutaneous Reduction ◽  
Posterior Malleolar Fracture ◽  
Posterior Malleolus

Introduction: The authors report the case of a 47-year-old patient who fell and experienced a sprained ankle that progressed to posterolateral fracture-dislocation of the ankle and Lauge-Hansen stage 4 supination-external rotation. Objective: To evaluate the use of posterior ankle endoscopy to facilitate the internal fixation of a posterior malleolar fracture.  Methods: Case report of a patient with posterolateral fracture-dislocation of the ankle and description of the use of endoscopy for treatment. Examinations performed in the emergency room showed evidence of posterior malleolar fracture with a typical Volkmann fragment and a Danis-Weber type-B lateral malleolar fracture with posterolateral dislocation of the ankle joint. After fracture immobilization, the patient underwent surgical treatment with posterior endoscopy of the ankle for visualization and for percutaneous fixation of the posterior malleolar fracture and open reduction, with internal fixation with a direct incision of the fibula (lateral malleolus). Results: The use of endoscopic and arthroscopic methods for the ankle has gained popularity, although there is still apprehension in using posterior endoscopy due to its limited visualization and less-comprehensive indication compared with anterior methods. Currently, posterior methods are indicated for osteochondral lesions of the subtalar joint, posterior malleolar and calcaneal fractures, tenosynovitis of the flexor hallucis longus and posterior synovitis. Despite the limited visualization, the use of endoscopy in this case enabled the percutaneous reduction and fixation of the posterior malleolus without requiring a classic posterior approach; consequently, the patient experienced less pain during the postoperative period and faster recovery than occurs with the classic incision. Conclusion: We expect that over time posterior endoscopy will be increasingly used among surgeons in cases of posterior malleolar fracture because it offers a shorter hospital stay and allows patients to resume their activities of daily living earlier. However, posterior endoscopy of the ankle is not without complications and has a steeper learning curve than anterior endoscopy. Therefore, knowledge of the anatomy, indications and technique is fundamental.

Arthroscopic Visualization of the Tibial Plafond During Posterior Malleolar Fracture Fixation

1994 ◽  
Vol 15 (4) ◽  
pp. 206-208 ◽  
Author(s):  
Edward S. Holt
Keyword(s):  
Internal Fixation ◽  
Fracture Fixation ◽  
Open Reduction ◽  
Articular Surface ◽  
Malleolar Fracture ◽  
Posterior Tibial ◽  
Tibial Plafond ◽  
Posterior Malleolus ◽  
Anatomic Reduction ◽  
Trimalleolar Fracture

Fracture of the tibial plafond, such as in a trimalleolar fracture, with a large posterior tibial (posterior malleolus) fragment may require open reduction and internal fixation. Anatomic reduction of the articular surface can be ensured by visualizing the articular surface using an arthroscope during reduction. Four cases wherein this technique has proven effective are described.

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