Therapeutic Management of the Posterior Malleolus in Trimaleolar Ankle Fractures. Review
Keywords:
Ankle Fractures (Mesh), Fractures Fixation (Mesh), Posterior Malleolus, Posterior Malleolar Fractures, Trimalleolar Fractures, Internal Fixation
Abstract
Introduction: The therapeutic management of posterior malleolus fractures in trimaleolar ankle fractures continues in debate. Our objective was to conduct a search for scientific evidence on the
therapeutic aspects of posterior malleolus fractures in the context of trimaleolar fractures.
Materials and methods: A review systematic of the literature was carried out by two reviewers, focusing on the therapeutic management of the posterior malleolus.
Results: 16 clinical articles were obtained with a total of 1029 patients, 8 studies level of evidence II and 8 studies level IV. The surgical indications were systematized, and the functional results
and complications were analyzed.
Conclusions: The patho-anatomical understanding of these fractures is increasing every day, mainly due to the usual use of CT scans. Surgical treatment on the posterior malleolus shows good and excellent functional results. For an adequate therapeutic decision certain factors should be taken into account: tibiotalar and syndesmotic instability, joint congruence and morphological characteristics of the posterior malleolus. Open reduction and internal fixation with support plate is the treatment that has shown better results in the short and medium term, not finding studies with long-term follow-up.
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References
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McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res. 1977;(122):37–45.
Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment:management and results. J Foot Ankle Surg. 2011;50(2):141–145.
Xu HL, Xuan L, Zhang DY, Fu Z, Wang T, Zhang P, et al. A retrospective study of posterior malleolus fractures. Int Orthop. 2012;36(9):1929–1936.
Ovaska M. Complications in ankle fracture surgery. Acta Ortho. 2015;86(358):1-32.
Verhage SM, Schipper IB, Hoogendoorn JM. Long-term functional and radiographic outcomes in 243 operated ankle fractures. J Foot Ankle Res. 2015;8:45.
Evers J, Barz L, Wähnert D, Grüneweller N, Raschke MJ, Ochman S. Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury. 2015;46(Suppl 4):S109-13.
Veltman ES, Halma JJ, de Gast A. Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature. Foot Ankle Surg. 2016;22(2):73-7.
Arastu MH, Demcoe R, Buckley RE. Current concepts review: ankle fractures. Acta Chir Orthop Traumatol Cech. 2012;79(6):473-83.
Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88(5):1085-92.
Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135(4):505-16.
Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin. 2017;22(1):125-145.
Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32(4):385–393.
Nelson MC, Jensen NK. The treatment of trimalleolar fractures of the ankle. Surg Gynecol Obst. 1940;71:509–14.
Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on long-termoutcome of posterior malleolar fractures. Foot Ankle Int. 2015;36(6):673-8.
Saygili MS, Özkul B, Çetinkaya, Tekin AC, Bayhan AI, Kalkar I, et al. Operative versus non-operative treatment of posterior malleolus fragment in trimalleolar fracture: A retrospective cohort study. Biomedical Research. 2017;28(14): 6498-6503.
Ruokun H, Ming X, Zhihong X, Zhenhua F, Jingjing Z, Kai X, et al. Postoperative radiographic and clinical assessment ofthe treatment of posterior tibial plafond fracture using posterior lateral incisional approach. J Foot Ankle Surg. 2014;53(6):678-
82.
Karaca S, Enercan M, Özdemir G, Kahraman S, Çobanoğlu M, Küçükkaya M. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. Ulus Travma Acil Cerrahi Derg. 2016;22(6):553-558.
Wang Y, Wang J, Luo CF. Modified posteromedial approach for treatment of posterior pilon variant fracture. BMC Musculo skeletal Disord. 2016;17:(328).
Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the management of fractures of the ankle: safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures. Bone Joint J.2017;99-B(11):1496-1501.
Sukur E, Akman YE, Gokcen HB, Ozyurek EC, Senel A, Ozturkmen Y. Open reduction in pilon variant posterior malleolar fractures: Radiologicaland clinical evaluation.Orthop Traumatol Surg Res. 2017 Sep;103(5):703-707.
Choi JY, Kim JH, Ko HT, Suh JS. Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures withan associated lateral malleolar fracture. J Foot Ankle Surg. 2015;54(4):559-64
Erdem MN, Erken HY, Burc H, Saka G, Korkmaz MF, Aydogan M. Comparison of lag screw versus buttress plate fixation of posterior malleolarfractures. Foot Ankle Int. 2014;35(10):1022-30.
Shi HF, Xiong J, Chen YX, Wang JF, Qiu XS, Huang J, et al. Comparison of the direct and indirect reduction techniques duringthe surgical management of posterior malleolar fractures; BMC Musculoskeletal Disord. 2017;18(1):109.
O’Connor TJ, Mueller B, Ly TV, Jacobson AR, Nelson ER, Cole PA. “A to p” screw versus posterolateral plate for posteriormallolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015;29(4):e151-6.
Li M, Collier RC, Hill BW, Slinkard N, Ly TV. Comparing different surgical techniques for addressing the posterior malleolus in supination external rotation ankle fractures and the need for syndesmotic screw fixation. J Foot Ankle Surg. 2017;56(4):730-734.
Zhong S, Shen L, Zhao JG, Chen J, Xie JF, Shi Q, et al. Comparison of posteromedial versus posterolateral approach for posterior malleolus fixation in trimalleolar ankle fractures. Orthop Surg. 2017;9(1):69-76.
Xing W, Xie P, Wang L, Liu C, Cui J, Zhang Z, et al. The application of intraoperative ankle dislocation approach in the treatment of the unstable trimalleolar fractures involving posterior ankle comminuted fracture: a retrospective cohort study. BMC Surg. 2018;18:23.
Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018;39(1):99-104.
Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013;21(1):32-40.
Ferries JS, De Coster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8(4):328–331.
Meijer DT, Doornberg JN, Sierevelt IN, Malle WH, van Dijk CN, Kerkhoffs GM, et al. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 2015;46(10):2024–2029.
Gonzalez O, Fleming JJ, Meyr AJ. Radiographic assessment of posterior malleolar ankle fractures. The Journal of Foot & Ankle Surgery. 2015;54(3):365–369.
Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int. 2013;34(5):697–704.
84.
McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res. 1977;(122):37–45.
Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment:management and results. J Foot Ankle Surg. 2011;50(2):141–145.
Xu HL, Xuan L, Zhang DY, Fu Z, Wang T, Zhang P, et al. A retrospective study of posterior malleolus fractures. Int Orthop. 2012;36(9):1929–1936.
Ovaska M. Complications in ankle fracture surgery. Acta Ortho. 2015;86(358):1-32.
Verhage SM, Schipper IB, Hoogendoorn JM. Long-term functional and radiographic outcomes in 243 operated ankle fractures. J Foot Ankle Res. 2015;8:45.
Evers J, Barz L, Wähnert D, Grüneweller N, Raschke MJ, Ochman S. Size matters: The influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury. 2015;46(Suppl 4):S109-13.
Veltman ES, Halma JJ, de Gast A. Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature. Foot Ankle Surg. 2016;22(2):73-7.
Arastu MH, Demcoe R, Buckley RE. Current concepts review: ankle fractures. Acta Chir Orthop Traumatol Cech. 2012;79(6):473-83.
Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88(5):1085-92.
Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135(4):505-16.
Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin. 2017;22(1):125-145.
Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32(4):385–393.
Nelson MC, Jensen NK. The treatment of trimalleolar fractures of the ankle. Surg Gynecol Obst. 1940;71:509–14.
Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on long-termoutcome of posterior malleolar fractures. Foot Ankle Int. 2015;36(6):673-8.
Saygili MS, Özkul B, Çetinkaya, Tekin AC, Bayhan AI, Kalkar I, et al. Operative versus non-operative treatment of posterior malleolus fragment in trimalleolar fracture: A retrospective cohort study. Biomedical Research. 2017;28(14): 6498-6503.
Ruokun H, Ming X, Zhihong X, Zhenhua F, Jingjing Z, Kai X, et al. Postoperative radiographic and clinical assessment ofthe treatment of posterior tibial plafond fracture using posterior lateral incisional approach. J Foot Ankle Surg. 2014;53(6):678-
82.
Karaca S, Enercan M, Özdemir G, Kahraman S, Çobanoğlu M, Küçükkaya M. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. Ulus Travma Acil Cerrahi Derg. 2016;22(6):553-558.
Wang Y, Wang J, Luo CF. Modified posteromedial approach for treatment of posterior pilon variant fracture. BMC Musculo skeletal Disord. 2016;17:(328).
Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the management of fractures of the ankle: safety and efficacy of posteromedial approach for Haraguchi type 2 posterior malleolar fractures. Bone Joint J.2017;99-B(11):1496-1501.
Sukur E, Akman YE, Gokcen HB, Ozyurek EC, Senel A, Ozturkmen Y. Open reduction in pilon variant posterior malleolar fractures: Radiologicaland clinical evaluation.Orthop Traumatol Surg Res. 2017 Sep;103(5):703-707.
Choi JY, Kim JH, Ko HT, Suh JS. Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures withan associated lateral malleolar fracture. J Foot Ankle Surg. 2015;54(4):559-64
Erdem MN, Erken HY, Burc H, Saka G, Korkmaz MF, Aydogan M. Comparison of lag screw versus buttress plate fixation of posterior malleolarfractures. Foot Ankle Int. 2014;35(10):1022-30.
Shi HF, Xiong J, Chen YX, Wang JF, Qiu XS, Huang J, et al. Comparison of the direct and indirect reduction techniques duringthe surgical management of posterior malleolar fractures; BMC Musculoskeletal Disord. 2017;18(1):109.
O’Connor TJ, Mueller B, Ly TV, Jacobson AR, Nelson ER, Cole PA. “A to p” screw versus posterolateral plate for posteriormallolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015;29(4):e151-6.
Li M, Collier RC, Hill BW, Slinkard N, Ly TV. Comparing different surgical techniques for addressing the posterior malleolus in supination external rotation ankle fractures and the need for syndesmotic screw fixation. J Foot Ankle Surg. 2017;56(4):730-734.
Zhong S, Shen L, Zhao JG, Chen J, Xie JF, Shi Q, et al. Comparison of posteromedial versus posterolateral approach for posterior malleolus fixation in trimalleolar ankle fractures. Orthop Surg. 2017;9(1):69-76.
Xing W, Xie P, Wang L, Liu C, Cui J, Zhang Z, et al. The application of intraoperative ankle dislocation approach in the treatment of the unstable trimalleolar fractures involving posterior ankle comminuted fracture: a retrospective cohort study. BMC Surg. 2018;18:23.
Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018;39(1):99-104.
Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013;21(1):32-40.
Ferries JS, De Coster TA, Firoozbakhsh KK, Garcia JF, Miller RA. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma. 1994;8(4):328–331.
Meijer DT, Doornberg JN, Sierevelt IN, Malle WH, van Dijk CN, Kerkhoffs GM, et al. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 2015;46(10):2024–2029.
Gonzalez O, Fleming JJ, Meyr AJ. Radiographic assessment of posterior malleolar ankle fractures. The Journal of Foot & Ankle Surgery. 2015;54(3):365–369.
Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, et al. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int. 2013;34(5):697–704.
Published
2026-08-13
How to Cite
Filippini Irazun, J. P. (2026). Therapeutic Management of the Posterior Malleolus in Trimaleolar Ankle Fractures. Review. Anales De La Facultad De Medicina, 7(1), e2020v7n1a6. https://doi.org/10.25184/anfamed2020v7n1a6
Section
Artículos de revisión
Copyright (c) 2020 Juan Pedro Filippini Irazun
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