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Posterior malleolus fractures


M. C. Solan, The posterior malleolus component of a fracture of the ankle is important, yet often
A. Sakellariou overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not
used enough. Posterior malleolus fractures are not difficult to fix. After reduction and
From Royal Surrey fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is
County Hospital and out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There
Frimley Park is therefore considerable merit in fixing most posterior malleolus fractures. An early post-
Hospital, Surrey, operative CT scan to ensure that accurate reduction has been achieved should also be
United Kingdom considered.
Cite this article: Bone Joint J 2017;99-B:1413–19.

Fractures of the ankle are common. Decisions fragment may be safely reduced and fixed. Pre-
about their management require a thorough vious papers have discussed fixation of the
appreciation of the bony and ligamentous posterior malleolus but have nearly always
components of the injury. This, in turn, focused on doing so through a posterolateral
requires a comprehensive understanding of the approach.7-9 This approach remains the most
normal anatomy, and of the different patterns frequently needed, but in complex ankle frac-
of injury. The Danis-Weber classification tures, axial imaging CT scans are recom-
system1,2 is simple to apply, and has become mended, as one benefit is helping to detect
entrenched in orthopaedic practice in the those patterns of posterior malleolus fractures
United Kingdom. It is, however, a poor guide that extend medially.3,10,11 In orthopaedic
as how to best manage these injuries. It should practice in the United Kingdom, it is common
be recognised that these fractures are not sim- for surgeons to ignore a posterior malleolus
ple and their operative fixation should not be fracture completely.
regarded as cases for trainees on which to ‘cut In this article, we explore the increasing evi-
their teeth’. dence to support fixation of these fractures.
Recent publications3,4 have drawn attention The variation in the way in which fractures of
to the fact that the most common patterns of the ankle are treated in the United Kingdom
fracture of the ankle, those that include a has been addressed in the recent publication of
 M. C. Solan, BSc MBBS
FRCS(Tr&Orth), Consultant Weber B fracture of the fibula, are a very het- ‘BOAST Standards for Trauma 12’12 and this
Orthopaedic Foot and Ankle erogeneous group. Even with a complete document makes important recommendations
Royal Surrey County Hospital, understanding of the injury, it is difficult to for their management. Departmental audit
Egerton Road, Guildford, decide whether the talus is stable or unstable in against these benchmarks should be encour-
Surrey GU2 7XX, UK
the mortise. If it is stable, there is a good case aged. One of the recommendations is that the
 A. Sakellariou, BSc MBBS
for non-operative management. Even where use of CT scans should be considered when
FRCS(Orth), Consultant
Orthopaedic Foot and Ankle there is potential instability, it may still be pos- assessing more complex fractures: “CT imag-
sible to avoid fixation. A recent annotation in ing may be helpful in defining fracture config-
Frimley Park Hospital,
Portsmouth Road, Frimley, the July edition of The Bone & Joint Journal5 uration in more complex patterns particularly
Surrey GU16 7UJ, UK
explored the current debate regarding how to where the posterior malleolus is involved.”12
Correspondence should be sent determine if a Weber B-type fracture is stable The goal is to provide detailed information
to M. C. Solan; email:
matthewsolan1@aol.com or unstable. about the pattern of the fracture before decid-
This issue of The Bone & Joint Journal ing management, and planning surgery. We
©2017 The British Editorial
Society of Bone & Joint includes a paper by Bali et al6 regarding the sur- believe that when this guidance is revised, the
Surgery gical treatment of complex posterior malleolus recommendation should be to emphasise that
BJJ-2017-1072 $2.00 fractures. The authors emphasise the impor- CT scans are not optional, but instead are an
tance of a CT scan to classify the fracture, and essential part of this process for all fractures
Bone Joint J
2017;99-B:1413–19. describe one way that a posteromedial where there is evidence, or suspicion, of a

VOL. 99-B, No. 11, NOVEMBER 2017 1413


even without fixation, after a sufficient period of immobili-

sation. This is because the posteroinferior tibiofibular liga-
ment connects the distal fibula and the posterior malleolus.
Accurate reduction cannot be assured, however, and an
intercalated fragment, which would only be seen on a CT
scan, is one possible reason for this.23 Also, if the lateral
malleolus fracture is fixed in isolation, because it is attached
by the posteroinferior tibiofibular ligament to the posterior
malleolus fragment, the latter may displace, and even small
degrees of displacement will affect the healing ‘length’ of the
posterior syndesmotic osseo-ligamentous component and,
Fig. 1
ultimately, result in posterolateral talar instability.
Post-operative CT confirms articular Furthermore, the surgeon who prefers to ignore the poste-
rior malleolus is extremely likely to recommend prolonged
periods of non-weight-bearing post-operatively, making the
fracture of the posterior malleolus. Plain radiographic recovery from injuries treated this way arduous and costly. If
analysis is a poor way of determining the size, site, and dis- the posterior malleolus is fixed, the patient can, as soon as
placement of a posterior malleolus fracture.13,14 Radio- the soft tissues permit, bear full weight through the
graphs taken in the Emergency Department may be ankle.24,25 This results in earlier discharge from hospital,
imperfect, due to the presence of back-slabs or splints, and physiotherapy, and return to daily activity and work.
because of difficulty with positioning of the patient. Even As implied above, when the posterior malleolus is
the best quality radiographs may be difficult to interpret, addressed surgically, the reduction needs to be accurate.
with low interobserver reliability. Inadequate radiographic Malreduction leads to difficulty reducing the fibula at the
analysis leads to underestimation and, occasionally, overes- next step of the operation, as well as to degenerative
timation of the severity of the injury. changes later.7,26 It is advisable to fix the posterior malleo-
The bigger question behind choice of imaging for tri- lus provisionally, and then check that the fibula reduces,
malleolar fractures, a question that the BOAST Guidance before it is fixed definitively. In order to improve the stand-
does not currently address is: why should we fix a posterior ards of fixation, there is a strong case for pre- and (early)
malleolus fracture? The first reason is that the posterior post-operative CT scans to ensure that the goals of the opera-
malleolus may include a portion of the articular surface of tion have been achieved (Fig. 1).27 Occasionally, if the result is
the distal tibia. The importance of this, in terms of articular disappointing, early revision may be required (Fig. 2). This is
congruity, is widely appreciated. However, the decision as a difficult decision to make, but likely to be easier than late
to whether to fix the fragment in order to restore the artic- correction involving an osteotomy.28,29
ular surface, has traditionally relied upon dogma rather The second reason for fixation of the posterior malleolus
than scientific evidence. Depending on to whom you listen, relates to the distal tibiofibular syndesmosis. Fixation of the
or where you trained, the posterior malleolus can be ‘safely posterior malleolus not only reduces the distal fibula to the
ignored’ unless it constitutes 20%, 25%, 30%, or an even correct length through the posteroinferior tibiofibular liga-
greater arbitrary proportion of the articular surface of the ment, but also, ensures the correct ‘working length’ and
tibia.15 These judgements are based on studies of the con- strength of this ligament and the distal tibiofibular joint,
tact pressure at the tibiotalar articulation. Some papers thereby negating any requirement for stabilisation of the
have shown that contact pressures at the articular surface syndesmosis. Indeed, once the fibular component of the
increase as the fragment of the posterior malleolus gets fracture is also fixed, at least half of the integrity and
larger.16-18 The stability of the joint is not affected, as long strength of the distal tibiofibular joint is restored. Further-
as the medial and lateral malleoli are intact. There are few more, the need for fixation of the syndesmosis with screws
long-term outcome studies that specifically investigate the or flexible fixation with a tightrope, is strongly associated
role of the posterior malleolus.19-21 There are none that we with a poor outcome.30 Leaving aside the controversy
are aware of that stratify results of treatment by the size of regarding removal of syndesmosis screws, there are signifi-
the posterior malleolar fragment. The threshold that an cant advantages with, for instance, early rehabilitation, if
individual surgeon chooses is likely to be based upon how the ankle can be rendered stable without fixation of the
averse he or she is to using techniques of fixation of frac- syndesmosis. Post-operative instructions after surgery
tures of the ankle beyond the standard ‘fibular lag screw involving screws to the syndesmosis will almost certainly
and neutralisation plate’. The arbitrary “one-third rule” include non-weight-bearing for a minimum of six weeks,
was introduced by Nelson and Jensen who, in 1940,22 and partial weight-bearing for a further period. If the fibula
reported on a very small series of patients. and the posterior malleolus have been fixed, rehabilitation
It is true that if the fibula is anatomically reduced and can be quicker, to the advantage of the patient and with
fixed, it is likely that the posterior malleolus will also heal, reduced societal costs.



Fig. 2

Early revision after CT confirms malreduction.

Fixation of the posterior malleolus therefore has several instability may be underestimated. The best way to deter-
advantages: restoration of the articular surface of the tibia; mine whether a Weber B-type fracture is SER II or SER IV,
accurate restoration of length of the fibula, helping to avoid and stable or unstable, is still a subject of considerable
malunion; and restoration of stability of the syndesmosis interest.5 Poor understanding leads to unnecessary fixation
with fewer patients requiring its fixation. in some cases, and inevitably, therefore, to some surgical
The Weber classification system, simple though it is, does complications that are avoidable.4
not help surgeons appreciate the pattern of the injury prop- In SER-type injuries, fixation of the posterior malleolus
erly. This is due to the focus being solely upon the fibula restores the articular surface of the tibia, reduces the fibula
fracture, while ignoring the ligamentous components of the to length, and allows early weight-bearing and rehabilita-
injury. The Lauge–Hansen classification31 is not a perfect tion. There is also improved stability of the syndesmosis.34
system but does emphasise the (mostly) predictable This is probably of minor importance with these Weber B-
sequence of injury to either bone or ligament.32,33 Using the type fractures, as there remains sufficient strength in the
most common supination-external rotation (SER) type of anteroinferior tibiofibular and interosseous ligaments. In a
injury as an example, stages I and II are consistent in adults randomised controlled trial, Pakarinen et al35 reported that
(stage I, partial injury to the anterior inferior tibiofibular even where the ‘Hook Test’ showed some widening of the
ligament; stage II, an oblique fibula fracture). In adoles- syndesmosis after fixation of a fibula fracture, there was no
cents, stage I may manifest as an avulsion fracture. As the benefit from additional hardware to the distal tibiofibular
ankle is subject to further force, the injury progresses to joint.35
stage III, with either rupture of the posteroinferior tibio- Pronation external rotation (PER) injuries, and the less
fibular ligament or, an avulsion fracture of the posterior common pronation/abduction injuries, lead to Weber C-
malleolus. Stage IV involves the medial side of the ankle, type fractures of the fibula. These are the injuries that most
with either a fracture of the medial malleolus or an injury to obviously include disruption to the syndesmosis. The pro-
the deltoid ligament. A stage IV injury may thus present nated position of the foot means that the medial structures
radiologically with only a fracture of the fibula with asso- are under tension first, as the deforming force is applied. In
ciated posterior and medial ligamentous injuries or, as a tri- a PER fracture, therefore, the medial injury (either rupture
malleolar fracture. The degree of instability of the latter is of the deltoid ligament, or a fracture of the medial malleo-
usually obvious, whereas, with the former, the extent of lus), is the first stage (PER stage I). In stages II to IV, the

VOL. 99-B, No. 11, NOVEMBER 2017


Table I. Systems for the classification of posterior malleolus fractures

Author Haraguchi et al 200611 (n = 57) Bartoníček et al 201510 (n = 141)

Analysis Axial CT (%) CT reconstructions (%)
Type 1 Posterolateral (67) Extraincisural (8)
Type 2 Medial extension (19) Posterolateral (52)
Type 3 Small shell (14) Posteromedial (28)
Type 4 Large posterolateral (9)
Type 5 Irregular osteoporotic (3)

Fig. 3

Consequences of poor fracture fixation: trimalle-

olar fracture; fibula malreduction; malreduced
posterior malleolus with anteroposterior screw;
tightrope fails to cross syndesmosis; and result-
ant early post-traumatic arthritis (one year post-

lateral side of the ankle is sequentially injured: stage II, fixation both in length and rotation of the fibula28,29
injury to the anteroinferior tibiofibular ligament or an avul- (Fig. 3). Reduction and fixation of the posterior malleolus,
sion fracture; stage III, fibular fracture (Weber C); stage IV, if a fracture is present, facilitates this.39 If there is no poste-
injury to the posteroinferior tibiofibular ligament or poste- rior malleolus fracture, open reduction of the syndesmosis,
rior malleolus fracture (or rarely fibular avulsion of the through an anterolateral incision, helps to restore the tibi-
posteroinferior tibiofibular ligament). ofibular position, prior to fixation using screw or flexible
Note that the components of stages I, II, and IV injuries transfibular fixation.40
may be either bony or ligamentous. A stage III injury is a There are two useful classifications of posterior malleo-
variably high fibular fracture. Where a particular compo- lus fractures, each based on CT findings (Table I).
nent of the injury presents with a fracture of the medial Haraguchi et al11 described three types of fracture in a
malleolus, the anterior syndesmosis (Tillaux36 or CT study of 57 patients, in 2006. Type 1, the most com-
Wagstaffe37 avulsions) or of the posterior malleolus, fixa- mon, is a single posterolateral fragment. In type 2, there is
tion is easier than if the injury is to the corresponding liga- extension to the posteromedial side of the distal tibia. There
ment. Fixation of these fractures restores stability more may be more than one fragment. Type 3 fractures are a thin
reliably than ligamentous repair. Fixation of a medial shell of bone. The classification is useful, as type 2 fractures
malleolus fracture gives more confidence than repair of the may demand a different surgical approach and type 3 frac-
deltoid ligament, for example. Biomechanical studies have tures may be too small or thin to allow fixation.
shown that reduction and fixation of the posterior malleo- Bartoniček et al3,10,23 used more advanced CT recon-
lus restores nearly half of the total strength of the syndes- structions to classify posterior malleolus fractures in 141
mosis.38 There is no additional benefit from fixation of the patients. Their system has four main types. They emphasise
syndesmosis if the posterior malleolus is fixed. Current con- the importance of recognising fractures that involve the
cepts of fixation of these injures emphasise accurate incisura, since accurate reduction will facilitate the



Fig. 4
Fixation with posterolateral buttress plating of the posterior and lateral

reduction and stability of the syndesmosis. As with the rather than one-third tubular, can be used in bridging
Haraguchi system, there is relevance to the choice of inci- mode, and prior reduction of the posterior malleolus frac-
sion. In particular, the identification of a posteromedial ture helps to ensure that the fibular length is restored accu-
fragment or the presence of any intercalated fragment is rately. With the posterior malleolus and the fibula both
useful for surgical planning. reduced and fixed, there is less likelihood that fixation of
Most posterior malleolus fractures can be approached the syndesmosis will be required, especially if the medial
using a posterolateral incision, being careful to identify and injury is to the medial malleolus and that is fixed too. If,
protect the sural nerve and its branches.7,41 A buttress plate however, the fibula fracture is too proximal for fixation
or lag screw can be used to fix the fracture.42 This is biome- with a plate, above the level of the middle of the bone,
chanically stronger, and a more logical approach than a reduction of the syndesmosis through an anterior incision
screw sited from the anterior tibia, which commonly pushes protecting the superficial peroneal nerve may be used to
the fragment away from, rather than lagging it to, the reduce the fibula in the incisura before fixation of the syn-
tibia.43 desmosis. The role of intramedullary fixation for these inju-
The same incision can be used for Weber B/SER type ries is an area of evolving interest.48-50
fractures to fix the fibular fracture with an anti-glide PER injuries are associated with a poor outcome, espe-
plate.44-46 No lag screw is required in the fibula. The plate cially if there is an associated dislocation.51 Even anatomi-
is used as a buttress and no screws are required in the distal cal reduction does not prevent arthritic change at medium-
fibular fragment (Fig. 4). Dissection around the fibula is term follow-up.52 Few studies specifically look at the out-
minimised. The displacement that any external rotation comes of posterior malleolus fractures. A definitive answer
force might produce is prevented. Early weight-bearing is sought by the study team conducting the Fixation of the
facilitates rapid recovery. The risk of irritation of the pero- Posterior Malleolus in Medium-sized Trimalleolar AO
neal tendons is minimal,47 especially if there are no distal Weber-B Fractures (POSTFix) trial.53
screws in the plate (i.e. it is a pure buttress plate). Unlike a De Vries et al19 followed up 45 patients at a mean of 13
lateral neutralisation plate or a ‘low-profile’ pre-contoured years. They were unable to distinguish differences in out-
locking plate, the hardware is not easily palpable, and the come with respect to the size of the posterior malleolus
need for subsequent removal of hardware is reduced. fragment or to its fixation. In 1989 in a series of 142 frac-
With Weber C/PER fractures, a second incision is usually tures followed for six years, Jaskulka et al20 found that any
needed to approach and fix the fibular fracture. A dynamic posterior malleolus fracture was associated with a poor
compression or limited contact dynamic compression plate, outcome, and that those cases where the fragment was

VOL. 99-B, No. 11, NOVEMBER 2017


fixed fared better than those managed without fixation. fixation, the articular surface of the tibia is restored, the fib-
Tejwani et al54 studied 456 patients. One year after injury, ula is out to length, the syndesmosis is more stable and at the
those with a posterior malleolus fracture scored less well on correct length, and the patient may rehabilitate more quickly
the Short Musculoskeletal Function Assessment.55 A retro- without fear of late displacement of the fracture. There is
spective analysis of 131 patients categorised posterior considerable merit in fixing most posterior malleolus frac-
malleolus fractures as small (< 5% of the articular surface), tures. An early post-operative CT scan should also be under-
medium (5% to 25%) and large (> 25%). At a mean taken to ensure that accurate reduction has been achieved.
follow-up of seven years, they found more arthritis in those
with medium or large fragments. The incidence of arthritis Take home message:
was higher where there was articular step-off of > 1 mm. - Posterior malleolus fractures are associated with a poor out-
Disappointingly, this still included over 40% of the patients
- Fixation restores the articular surface and reduces the need for stabilisa-
in whom the posterior malleolus had been fixed.56 The tion of the syndesmosis
authors of a CT-based study dismissed earlier papers that - CT scans help classify the fracture
are based on plain radiographs. However, their own retro- - The surgical treatment of fractures of the ankle should not be delegated
spective series had CT data for only 57% of the 42 patients. to junior surgeons
There was also a shorter follow-up of 2.5 years.57 Author contributions:
The Curriculum for Training in Trauma and Orthopae- M. C. Solan: Literature search, Collection and analysis of data, Writing the
dic Surgery in the United Kingdom continues to evolve.11 In A. Sakellariou: Literature search, Writing the paper.
the early years, trainees are encouraged to gain experience
No benefits in any form have been received or will be received from a commer-
in the operative treatment of common fractures. Based on cial party related directly or indirectly to the subject of this article.
the historical premise that Weber B fractures all require sur-
This article was primary edited by J. Scott.
gical treatment, and that the standard lag screw with a neu-
tralisation plate is a good training operation, the
curriculum expects core trainees to be able to fix fractures References
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