Posterior malleolus fractures: Worth fixing

Abstract

The posterior malleolus component of a fracture of the ankle is important, yet often 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 fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered.
Cite this article: Bone Joint J 2017;99-B:1413–19.

Full text

VOL. 99-B, No. 11, NOVEMBER 2017 1413
ANNOTATION
Posterior malleolus fractures
WORTH FIXING
M. C. Solan,
A. Sakellariou
From Royal Surrey
County Hospital and
Frimley Park
Hospital, Surrey,
United Kingdom
M. C. Solan, BSc MBBS
FRCS(Tr&Orth), Consultant
Orthopaedic Foot and Ankle
Surgeon
Royal Surrey County Hospital,
Egerton Road, Guildford,
Surrey GU2 7XX, UK
A. Sakellariou, BSc MBBS
FRCS(Orth), Consultant
Orthopaedic Foot and Ankle
Surgeon
Frimley Park Hospital,
Portsmouth Road, Frimley,
Surrey GU16 7UJ, UK
Correspondence should be sent
to M. C. Solan; email:
matthewsolan1@aol.com
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B11.
BJJ-2017-1072 $2.00
Bone Joint J
2017;99-B:1413–19.
The posterior malleolus component of a fracture of the ankle is important, yet often
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
fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is
out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There
is therefore considerable merit in fixing most posterior malleolus fractures. An early post-
operative CT scan to ensure that accurate reduction has been achieved should also be
considered.
Cite this article: Bone Joint J 2017;99-B:1413–19.
Fractures of the ankle are common. Decisions
about their management require a thorough
appreciation of the bony and ligamentous
components of the injury. This, in turn,
requires a comprehensive understanding of the
normal anatomy, and of the different patterns
of injury. The Danis-Weber classification
system1,2 is simple to apply, and has become
entrenched in orthopaedic practice in the
United Kingdom. It is, however, a poor guide
as how to best manage these injuries. It should
be recognised that these fractures are not sim-
ple and their operative fixation should not be
regarded as cases for trainees on which to ‘cut
their teeth’.
Recent publications3,4 have drawn attention
to the fact that the most common patterns of
fracture of the ankle, those that include a
Weber B fracture of the fibula, are a very het-
erogeneous group. Even with a complete
understanding of the injury, it is difficult to
decide whether the talus is stable or unstable in
the mortise. If it is stable, there is a good case
for non-operative management. Even where
there is potential instability, it may still be pos-
sible to avoid fixation. A recent annotation in
the July edition of The Bone & Joint Journal5
explored the current debate regarding how to
determine if a Weber B-type fracture is stable
or unstable.
This issue of The Bone & Joint Journal
includes a paper by Bali et al6 regarding the sur-
gical treatment of complex posterior malleolus
fractures. The authors emphasise the impor-
tance of a CT scan to classify the fracture, and
describe one way that a posteromedial
fragment may be safely reduced and fixed. Pre-
vious papers have discussed fixation of the
posterior malleolus but have nearly always
focused on doing so through a posterolateral
approach.7-9 This approach remains the most
frequently needed, but in complex ankle frac-
tures, axial imaging CT scans are recom-
mended, as one benefit is helping to detect
those patterns of posterior malleolus fractures
that extend medially.3,10,11 In orthopaedic
practice in the United Kingdom, it is common
for surgeons to ignore a posterior malleolus
fracture completely.
In this article, we explore the increasing evi-
dence to support fixation of these fractures.
The variation in the way in which fractures of
the ankle are treated in the United Kingdom
has been addressed in the recent publication of
‘BOAST Standards for Trauma 12’12 and this
document makes important recommendations
for their management. Departmental audit
against these benchmarks should be encour-
aged. One of the recommendations is that the
use of CT scans should be considered when
assessing more complex fractures: “CT imag-
ing may be helpful in defining fracture config-
uration in more complex patterns particularly
where the posterior malleolus is involved.”12
The goal is to provide detailed information
about the pattern of the fracture before decid-
ing management, and planning surgery. We
believe that when this guidance is revised, the
recommendation should be to emphasise that
CT scans are not optional, but instead are an
essential part of this process for all fractures
where there is evidence, or suspicion, of a

1414 M. C. SOLAN, A. SAKELLARIOU
THE BONE & JOINT JOURNAL
fracture of the posterior malleolus. Plain radiographic
analysis is a poor way of determining the size, site, and dis-
placement of a posterior malleolus fracture.13,14 Radio-
graphs taken in the Emergency Department may be
imperfect, due to the presence of back-slabs or splints, and
because of difficulty with positioning of the patient. Even
the best quality radiographs may be difficult to interpret,
with low interobserver reliability. Inadequate radiographic
analysis leads to underestimation and, occasionally, overes-
timation of the severity of the injury.
The bigger question behind choice of imaging for tri-
malleolar fractures, a question that the BOAST Guidance
does not currently address is: why should we fix a posterior
malleolus fracture? The first reason is that the posterior
malleolus may include a portion of the articular surface of
the distal tibia. The importance of this, in terms of articular
congruity, is widely appreciated. However, the decision as
to whether to fix the fragment in order to restore the artic-
ular surface, has traditionally relied upon dogma rather
than scientific evidence. Depending on to whom you listen,
or where you trained, the posterior malleolus can be ‘safely
ignored’ unless it constitutes 20%, 25%, 30%, or an even
greater arbitrary proportion of the articular surface of the
tibia.15 These judgements are based on studies of the con-
tact pressure at the tibiotalar articulation. Some papers
have shown that contact pressures at the articular surface
increase as the fragment of the posterior malleolus gets
larger.16-18 The stability of the joint is not affected, as long
as the medial and lateral malleoli are intact. There are few
long-term outcome studies that specifically investigate the
role of the posterior malleolus.19-21 There are none that we
are aware of that stratify results of treatment by the size of
the posterior malleolar fragment. The threshold that an
individual surgeon chooses is likely to be based upon how
averse he or she is to using techniques of fixation of frac-
tures of the ankle beyond the standard ‘fibular lag screw
and neutralisation plate’. The arbitrary “one-third rule”
was introduced by Nelson and Jensen who, in 1940,22
reported on a very small series of patients.
It is true that if the fibula is anatomically reduced and
fixed, it is likely that the posterior malleolus will also heal,
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,
ultimately, result in posterolateral talar instability.
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
recovery from injuries treated this way arduous and costly. If
the posterior malleolus is fixed, the patient can, as soon as
the soft tissues permit, bear full weight through the
ankle.24,25 This results in earlier discharge from hospital,
physiotherapy, and return to daily activity and work.
As implied above, when the posterior malleolus is
addressed surgically, the reduction needs to be accurate.
Malreduction leads to difficulty reducing the fibula at the
next step of the operation, as well as to degenerative
changes later.7,26 It is advisable to fix the posterior malleo-
lus provisionally, and then check that the fibula reduces,
before it is fixed definitively. In order to improve the stand-
ards of fixation, there is a strong case for pre- and (early)
post-operative CT scans to ensure that the goals of the opera-
tion have been achieved (Fig. 1).27 Occasionally, if the result is
disappointing, early revision may be required (Fig. 2). This is
a difficult decision to make, but likely to be easier than late
correction involving an osteotomy.28,29
The second reason for fixation of the posterior malleolus
relates to the distal tibiofibular syndesmosis. Fixation of the
posterior malleolus not only reduces the distal fibula to the
correct length through the posteroinferior tibiofibular liga-
ment, but also, ensures the correct ‘working length’ and
strength of this ligament and the distal tibiofibular joint,
thereby negating any requirement for stabilisation of the
syndesmosis. Indeed, once the fibular component of the
fracture is also fixed, at least half of the integrity and
strength of the distal tibiofibular joint is restored. Further-
more, the need for fixation of the syndesmosis with screws
or flexible fixation with a tightrope, is strongly associated
with a poor outcome.30 Leaving aside the controversy
regarding removal of syndesmosis screws, there are signifi-
cant advantages with, for instance, early rehabilitation, if
the ankle can be rendered stable without fixation of the
syndesmosis. Post-operative instructions after surgery
involving screws to the syndesmosis will almost certainly
include non-weight-bearing for a minimum of six weeks,
and partial weight-bearing for a further period. If the fibula
and the posterior malleolus have been fixed, rehabilitation
can be quicker, to the advantage of the patient and with
reduced societal costs.
Fig. 1
Post-operative CT confirms articular
reduction.

POSTERIOR MALLEOLUS FRACTURES 1415
VOL. 99-B, No. 11, NOVEMBER 2017
Fixation of the posterior malleolus therefore has several
advantages: restoration of the articular surface of the tibia;
accurate restoration of length of the fibula, helping to avoid
malunion; and restoration of stability of the syndesmosis
with fewer patients requiring its fixation.
The Weber classification system, simple though it is, does
not help surgeons appreciate the pattern of the injury prop-
erly. This is due to the focus being solely upon the fibula
fracture, while ignoring the ligamentous components of the
injury. The Lauge–Hansen classification31 is not a perfect
system but does emphasise the (mostly) predictable
sequence of injury to either bone or ligament.32,33 Using the
most common supination-external rotation (SER) type of
injury as an example, stages I and II are consistent in adults
(stage I, partial injury to the anterior inferior tibiofibular
ligament; stage II, an oblique fibula fracture). In adoles-
cents, stage I may manifest as an avulsion fracture. As the
ankle is subject to further force, the injury progresses to
stage III, with either rupture of the posteroinferior tibio-
fibular ligament or, an avulsion fracture of the posterior
malleolus. Stage IV involves the medial side of the ankle,
with either a fracture of the medial malleolus or an injury to
the deltoid ligament. A stage IV injury may thus present
radiologically with only a fracture of the fibula with asso-
ciated posterior and medial ligamentous injuries or, as a tri-
malleolar fracture. The degree of instability of the latter is
usually obvious, whereas, with the former, the extent of
instability may be underestimated. The best way to deter-
mine whether a Weber B-type fracture is SER II or SER IV,
and stable or unstable, is still a subject of considerable
interest.5 Poor understanding leads to unnecessary fixation
in some cases, and inevitably, therefore, to some surgical
complications that are avoidable.4
In SER-type injuries, fixation of the posterior malleolus
restores the articular surface of the tibia, reduces the fibula
to length, and allows early weight-bearing and rehabilita-
tion. There is also improved stability of the syndesmosis.34
This is probably of minor importance with these Weber B-
type fractures, as there remains sufficient strength in the
anteroinferior tibiofibular and interosseous ligaments. In a
randomised controlled trial, Pakarinen et al35 reported that
even where the ‘Hook Test’ showed some widening of the
syndesmosis after fixation of a fibula fracture, there was no
benefit from additional hardware to the distal tibiofibular
joint.35
Pronation external rotation (PER) injuries, and the less
common pronation/abduction injuries, lead to Weber C-
type fractures of the fibula. These are the injuries that most
obviously include disruption to the syndesmosis. The pro-
nated position of the foot means that the medial structures
are under tension first, as the deforming force is applied. In
a PER fracture, therefore, the medial injury (either rupture
of the deltoid ligament, or a fracture of the medial malleo-
lus), is the first stage (PER stage I). In stages II to IV, the
Fig. 2
Early revision after CT confirms malreduction.

1416 M. C. SOLAN, A. SAKELLARIOU
THE BONE & JOINT JOURNAL
lateral side of the ankle is sequentially injured: stage II,
injury to the anteroinferior tibiofibular ligament or an avul-
sion fracture; stage III, fibular fracture (Weber C); stage IV,
injury to the posteroinferior tibiofibular ligament or poste-
rior malleolus fracture (or rarely fibular avulsion of the
posteroinferior tibiofibular ligament).
Note that the components of stages I, II, and IV injuries
may be either bony or ligamentous. A stage III injury is a
variably high fibular fracture. Where a particular compo-
nent of the injury presents with a fracture of the medial
malleolus, the anterior syndesmosis (Tillaux36 or
Wagstaffe37 avulsions) or of the posterior malleolus, fixa-
tion is easier than if the injury is to the corresponding liga-
ment. Fixation of these fractures restores stability more
reliably than ligamentous repair. Fixation of a medial
malleolus fracture gives more confidence than repair of the
deltoid ligament, for example. Biomechanical studies have
shown that reduction and fixation of the posterior malleo-
lus restores nearly half of the total strength of the syndes-
mosis.38 There is no additional benefit from fixation of the
syndesmosis if the posterior malleolus is fixed. Current con-
cepts of fixation of these injures emphasise accurate
fixation both in length and rotation of the fibula28,29
(Fig. 3). Reduction and fixation of the posterior malleolus,
if a fracture is present, facilitates this.39 If there is no poste-
rior malleolus fracture, open reduction of the syndesmosis,
through an anterolateral incision, helps to restore the tibi-
ofibular position, prior to fixation using screw or flexible
transfibular fixation.40
There are two useful classifications of posterior malleo-
lus fractures, each based on CT findings (Table I).
Haraguchi et al11 described three types of fracture in a
CT study of 57 patients, in 2006. Type 1, the most com-
mon, is a single posterolateral fragment. In type 2, there is
extension to the posteromedial side of the distal tibia. There
may be more than one fragment. Type 3 fractures are a thin
shell of bone. The classification is useful, as type 2 fractures
may demand a different surgical approach and type 3 frac-
tures may be too small or thin to allow fixation.
Bartoniček et al3,10,23 used more advanced CT recon-
structions to classify posterior malleolus fractures in 141
patients. Their system has four main types. They emphasise
the importance of recognising fractures that involve the
incisura, since accurate reduction will facilitate the
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-
operatively).

POSTERIOR MALLEOLUS FRACTURES 1417
VOL. 99-B, No. 11, NOVEMBER 2017
reduction and stability of the syndesmosis. As with the
Haraguchi system, there is relevance to the choice of inci-
sion. In particular, the identification of a posteromedial
fragment or the presence of any intercalated fragment is
useful for surgical planning.
Most posterior malleolus fractures can be approached
using a posterolateral incision, being careful to identify and
protect the sural nerve and its branches.7,41 A buttress plate
or lag screw can be used to fix the fracture.42 This is biome-
chanically stronger, and a more logical approach than a
screw sited from the anterior tibia, which commonly pushes
the fragment away from, rather than lagging it to, the
tibia.43
The same incision can be used for Weber B/SER type
fractures to fix the fibular fracture with an anti-glide
plate.44-46 No lag screw is required in the fibula. The plate
is used as a buttress and no screws are required in the distal
fibular fragment (Fig. 4). Dissection around the fibula is
minimised. The displacement that any external rotation
force might produce is prevented. Early weight-bearing
facilitates rapid recovery. The risk of irritation of the pero-
neal tendons is minimal,47 especially if there are no distal
screws in the plate (i.e. it is a pure buttress plate). Unlike a
lateral neutralisation plate or a ‘low-profile’ pre-contoured
locking plate, the hardware is not easily palpable, and the
need for subsequent removal of hardware is reduced.
With Weber C/PER fractures, a second incision is usually
needed to approach and fix the fibular fracture. A dynamic
compression or limited contact dynamic compression plate,
rather than one-third tubular, can be used in bridging
mode, and prior reduction of the posterior malleolus frac-
ture helps to ensure that the fibular length is restored accu-
rately. With the posterior malleolus and the fibula both
reduced and fixed, there is less likelihood that fixation of
the syndesmosis will be required, especially if the medial
injury is to the medial malleolus and that is fixed too. If,
however, the fibula fracture is too proximal for fixation
with a plate, above the level of the middle of the bone,
reduction of the syndesmosis through an anterior incision
protecting the superficial peroneal nerve may be used to
reduce the fibula in the incisura before fixation of the syn-
desmosis. The role of intramedullary fixation for these inju-
ries is an area of evolving interest.48-50
PER injuries are associated with a poor outcome, espe-
cially if there is an associated dislocation.51 Even anatomi-
cal reduction does not prevent arthritic change at medium-
term follow-up.52 Few studies specifically look at the out-
comes of posterior malleolus fractures. A definitive answer
is sought by the study team conducting the Fixation of the
Posterior Malleolus in Medium-sized Trimalleolar AO
Weber-B Fractures (POSTFix) trial.53
De Vries et al19 followed up 45 patients at a mean of 13
years. They were unable to distinguish differences in out-
come with respect to the size of the posterior malleolus
fragment or to its fixation. In 1989 in a series of 142 frac-
tures followed for six years, Jaskulka et al20 found that any
posterior malleolus fracture was associated with a poor
outcome, and that those cases where the fragment was
Fig. 4
Fixation with posterolateral buttress plating of the posterior and lateral
malleoli.

1418 M. C. SOLAN, A. SAKELLARIOU
THE BONE & JOINT JOURNAL
fixed fared better than those managed without fixation.
Tejwani et al54 studied 456 patients. One year after injury,
those with a posterior malleolus fracture scored less well on
the Short Musculoskeletal Function Assessment.55 A retro-
spective analysis of 131 patients categorised posterior
malleolus fractures as small (< 5% of the articular surface),
medium (5% to 25%) and large (> 25%). At a mean
follow-up of seven years, they found more arthritis in those
with medium or large fragments. The incidence of arthritis
was higher where there was articular step-off of > 1 mm.
Disappointingly, this still included over 40% of the patients
in whom the posterior malleolus had been fixed.56 The
authors of a CT-based study dismissed earlier papers that
are based on plain radiographs. However, their own retro-
spective series had CT data for only 57% of the 42 patients.
There was also a shorter follow-up of 2.5 years.57
The Curriculum for Training in Trauma and Orthopae-
dic Surgery in the United Kingdom continues to evolve.11 In
the early years, trainees are encouraged to gain experience
in the operative treatment of common fractures. Based on
the historical premise that Weber B fractures all require sur-
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
of the ankle. Progression through higher surgical training
and achieving a Certificate of Completion of Training is
dependent, in part, on adequate logbook experience. Spe-
cific minimum numbers of “indicative surgical procedures”
are offered by the Surgical Advisory Committee, as a guide
to the training committees who assess the competence of
their trainees. Currently, trainees are expected, during their
six years of higher training, to have been the primary sur-
geon for 40 operations to fix a fracture of the ankle.
Modern understanding of these fractures means that a
much higher proportion are managed non-operatively.
Patients who require surgery have complex and unstable
injures, often with significant associated soft-tissue dam-
age. Trainee surgeons at the start of their careers (Core
Training) are not equipped to undertake these operations.
Higher trainees will be exposed to fewer “simple ORIFs”
during their six years and they require close supervision
when making decisions about, and undertaking fixation of
injuries that require surgery. The Curriculum requirement
to “fix 40 ankles” is a blunt means of assessing competence
in the management of these injuries. As the proportion of
ankles that are treated surgically falls, and the frequency
with which specialty registrars are on-call for trauma
reduces, the proscribed number may even be unobtainable.
In conclusion, the posterior malleolus component of a
fracture of the ankle is an important and often overlooked
part of these common injuries. The Weber classification is
too simple to guide treatment and not useful. The routine
pre-operative use of CT scans to identify and classify the pat-
tern of the fracture is not practised widely enough in the
United Kingdom, or indeed, worldwide. Posterior malleolus
fractures are not difficult to fix. After their reduction and
fixation, the articular surface of the tibia is restored, the fib-
ula is out to length, the syndesmosis is more stable and at the
correct length, and the patient may rehabilitate more quickly
without fear of late displacement of the fracture. There is
considerable merit in fixing most posterior malleolus frac-
tures. An early post-operative CT scan should also be under-
taken to ensure that accurate reduction has been achieved.
Take home message:
- Posterior malleolus fractures are associated with a poor out-
come
- Fixation restores the articular surface and reduces the need for stabilisa-
tion of the syndesmosis
- CT scans help classify the fracture
- The surgical treatment of fractures of the ankle should not be delegated
to junior surgeons
Author contributions:
M. C. Solan: Literature search, Collection and analysis of data, Writing the
paper.
A. Sakellariou: Literature search, Writing the paper.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott.
References
1. Danis R. Les fractures malleolaires. In: Danis R (ed). Theorie et pratique de l'osteo-
synthese. Paris: Masson, 1949.
2. Weber BG. Die verletzungen des oberen sprunggelenkes. Second ed. Berne: Verlag
Hans Huber, 1972.
3. Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: changing con-
cepts and recent developments. Foot Ankle Clin 2017;22:125–145.
4. Dawe EJ, Shafafy R, Quayle J, et al. The effect of different methods of stability
assessment on fixation rate and complications in supination external rotation (SER) 2/
4 ankle fractures. Foot Ankle Surg 2015;21:86–90.
5. Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus
not so simple? how to assess stability, which ones to fix and the role of the deltoid lig-
ament. Bone Joint J 2017;99-B:851–855.
6. Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the man-
agement of fractures of the ankle: safety and efficacy of posteromedial approach for
Haraguchi type 2 posterior malleolar fractures. Bone Joint J 2017;99-B:1496–1501.
7. Tornetta P III, Ricci W, Nork S, Colli nge C, Steen B. The posterolateral approach
to the tibia for displaced posterior malleolar injuries. J Orthop Trauma 2011;25:123–
126.
8. Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg
2013;21:32–40.
9. Verhage SM, Boot F, Schipper IB, Hoogendoorn JM. Open reduction and inter-
nal fixation of posterior malleolar fractures using the posterolateral approach. Bone
Joint J 2016;98-B:812–817.
10. Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the
ankle. Eur J Trauma Emerg Surg 2015;41:587–600.
11. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar
fractures of the ankle. J Bone Joint Surg [Am] 2006;88-A:1085–1092.
12. No authors listed. BOA Standards for Trauma (BOASTSs) https://www.boa.ac.uk/
publications/boa-standards -trauma-boasts/#toggle-id-13 (date last accessed 3 Octo-
ber 2017).
13. Büchler L, Tannast M, Bonel HM, Weber M. Reliability of radiologic assessment
of the fracture anatomy at the poster ior tibial plafond in malleolar fractures. J Orthop
Tra u ma 2009;23:208–212.
14. Meijer DT, Doornberg JN, Sierevelt IN, et al. Guesstimation of posterior malle-
olar fractures on lateral plain radiographs. Injury 2015;46:2024–2029.
15. Gardner MJ, Streubel PN, McCormick JJ, et al. Surgeon practices regarding
operative treatment of posterior malleolus fractures. Foot Ankle Int 2011;32:385–393.
16. Hunt KJ, Goeb Y, Behn AW, Criswell B, Chou L. Ankle joint contact loads and dis-
placement with progressive syndesmotic injury. Foot Ankle Int 2015;36:1095–1103.

POSTERIOR MALLEOLUS FRACTURES 1419
VOL. 99-B, No. 11, NOVEMBER 2017
17. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area.
Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res
1995;320:182–187.
18. Vrahas M, Fu F, Veenis B. Intraarticular contact stresses with simulated ankle mal-
unions. J Orthop Trauma 1994;8:159–166.
19. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Long-term results of ankle
fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005;44:211–217.
20. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role
in the prognosis of malleolar fractures. J Trauma 1989;29:1565–1570.
21. Lindsjo U. Operative treatment of ankle fracture-dislocations. A follow-up study of
306/321 consecutive cases. Clin Orthop Relat Res 1985;199:28–38.
22. Nelson MC, Jensen NK. The treatment of trimalleolar fractures of the ankle. Surg
Gynec Obst 1940;71:509–514.
23. Bartoníček J, Rammelt S, Kostlivý K, et al. Anatomy and classification of the pos-
terior tibial fragment in ankle fractures. Arch Orthop Trauma Surg 2015;135:505–516.
24. Tan EW, Sirisreetreerux N, Paez AG, et al. Early Weightbearing After Operatively
Treated Ankle Fractures: A Biomechanical Analysis. Foot Ankle Int 2016;37:652–658.
25. Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E. Early weight
bearing after posterior malleolar fractures: an experimental and prospective clinical
study. J Foot Ankle Surg 2003;42:99–104.
26. Tenenbaum S, Shazar N, Bruck N, Bariteau J. Posterior malleolus fractures.
Orthop Clin North Am 2017;48:81–89.
27. Palmanovich E, Brin YS, Kish B, Nyska M, Hetsroni I. Value of early postopera-
tive computed tomography assessment in ankle fractures defining joint congruity and
criticizing the need for early revision surgery. J Foot Ankle Surg 2016;55:465–469.
28. Weber M, Ganz R. Malunion following trimalleolar fracture with posterolateral sub-
luxation of the talus--reconstruction including the posterior malleolus. Foot Ankle Int
2003;24:338–344.
29. Weber D, Weber M. Corrective osteotomies for malunited malleolar fractures. Foot
Ankle Clin 2016;21:37–48.
30. Egol KA, Pahk B, Walsh M, et al. Outcome after unstable ankle fracture: effect of
syndesmotic stabilization. J Orthop Trauma 2010;24:7–11.
31. Lauge-Hansen N. Fractures of the ankle: II. Combined experimental-surgical and
experimental-roentgenologic investigations. Arch Surg 1950;60:957–985.
32. Hinds RM, Schottel PC, Berkes MB, et al. Evaluation of Lauge-Hansen designa-
tion of Weber C fractures. J Foot Ankle Surg 2014;53:434–439.
33. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The ability
of the Lauge-Hansen classificat ion to predict ligament injury and mechanism in ankle
fractures: an MRI study. J Orthop Trauma 2006;20:267–272.
34. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar sta-
bilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res
2010;468:1129–1135.
35. Pakarinen HJ, Flinkkilä TE, Ohtonen PP, et al. Syndesmotic fixation in supina-
tion-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int
2011;32:1103–1109.
36. Tillaux P. Trait de chirgurie clinique. volume 2, Paris, Asselin and Houzeau, 1848.
37. Wagstaffe WW. An unusual form of fracture to the fibula. St Thomas Hospital
Reports. 6:43, 1875.
38. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of poste-
rior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res
2006;447:165–171.
39. Sagi HC , Shah AR, Sanders RW. The functional consequence of syndesmotic joint
malreduction at a minimum 2-year follow-up. J Orthop Trauma 2012;26:439–443.
40. Miller AN, Carroll EA, Parker RJ, et al. Direct visualization for syndesmotic sta-
bilization of ankle fractures. Foot Ankle Int 2009;30:419–426.
41. Forberger J, Sabandal PV, Dietrich M, et al. Posterolateral approach to the dis-
placed posterior malleolus: functional outcome and local morbidity. Foot Ankle Int
2009;30:309–314.
42. Ha rtwich K, Lorente Gomez A, Pyrc J, et al. Biomechanical analysis of stability of
posterior antiglide plating in osteoporotic pronation abduction ankle fracture model
with posterior tibial fragment. Foot Ankle Int 2017;38:58–65.
43. O'Connor TJ, Mueller B, Ly TV, et a l. “A to p” screw versus posterolateral pl ate for
posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma
2015;29:151–156.
44. Fl eming JJ, Kooner RK, Soondar S. Use of a posterior antiglide plate in a pediatric
ankle fracture: a case report. J Foot Ankle Surg 2009;48:469–473.
45. Treadwell JR, Fallat LM. The antiglide plate for the Danis-Weber type-B fibular
fracture: a review of 71 cases. J Foot Ankle Surg 1993;32:573–579.
46. Harper MC. The antiglide plate for distal fibular fixation. A biomechanical compari-
son with fixation with a lateral plate. J Bone Joint Surg [Am] 1988;70-A:149–150.
47. Ahn J, Kim S, Lee JS, Woo K, Sung KS. Incidence of peroneal tendinopathy after
application of a posterior antiglide plate for repair of supination external rotation lat-
eral malleolar fractures. J Foot Ankle Surg 2016;55:90–93.
48. Bugler KE, Watson CD, Hardie AR, et al. The treatment of unstable fractures of
the ankle using the Acumed fibular nail: par development of a technique. J Bone Joint
Surg [Br] 2012;94-B:1107–1112.
49. Switaj PJ, Fuchs D, Alshouli M, et al. A biomechanical comparison study of a
modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures. J
Orthop Surg Res 2016;11:100.
50. Asloum Y, B edin B, Roger T, et al. Internal fixation of the fibula in ankle fractures:
a prospective, randomized and comparative study: plating versus nailing. Orthop Trau-
matol Surg Res 2014;100(4 Suppl):S255–S259.
51. Warner SJ, Schottel PC, Hinds RM, Helfet DL, Lorich DG. Fracture-dislocations
demonstrate poorer postoperative functional outcomes among pronation external
rotation IV Ankle fractures. Foot Ankle Int 2015;36:641–647.
52. Heim D, Niede rhauser K, Simbrey N. The Volkmann dogma: a retrospective, long-
term, single-center study. Eur J Trauma Emerg Surg 2010;36:515–519.
53. Verhage S, van der Zwaal P, Bronkhorst M, et al. Medium-sized posterior frag-
ments in AO Weber-B fractures, does open reduction and fixation improve outcome?
the POSTFIX-trial protocol, a multicenter randomized clinical trial. BMC Musculo-
skelet Disord 2017;18:94.
54. Tejwani NC, Pahk B, Egol KA. Effect of posterior malleolus fracture on outcome
after unstable ankle fracture. J Trauma 2010;69:666–669.
55. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short musculoskeletal func-
tion assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint
Surg [Am] 1999;81-A:1245–1260.
56. Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment
size and postoperative joint congruency on long-term outcome of posterior malleolar
fractures. Foot Ankle Int 2015;36:673–678.
57. Ever s J, Barz L, Wähnert D, et al. Size matters: The influence of the posterior frag-
ment on patient outcomes in trimalleolar ankle fractures. Injury 2015;46(Suppl
4):S109–S113.