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Title: Advances and disputes of posterior malleolus fracture: A review
of literature
Authors: Su FU, Zhenlyu ZOU, Gang MEI and Dan JIN*
Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern
Medical University, Guangzhou 510515, China
*
Correspondence Author: Dan Jin, MD PhD
Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern
Medical University 1838, North Guangzhou Avenue, Guangzhou City,
Guangdong Province, 510515， P.R.China
Email: [email protected]
Tel: +86-20-62787951
Fax: +86-20-61360066
Key words: posterior malleolus fracture; stability; CT; posterolateral
approach; syndesmotic fixation
ABSTRACT
Objective to summarize the development of posterior malleolus fracture
Data sources Data used in this review were mainly from Pubmed in English
Study selection Articles were included in the review if they were related
to the posterior malleolus or trimalleolar fracture.
Results No consensus is found regarding what sizes of posterior malleolar
fragments would lead to ankle instability thus affecting prognosis, and
should be fixed. X-ray measurement is unreliable, while CT scan is widely
recommended and it can recognize the occult posterior malleolar fractures
associated with tibia shaft fractures, which is always undetected
previously. Direct posterior malleolus fixation is suitable to stabilize
syndesmotic injury. The basic and clinical researches support direct
reduction and buttress plate fixation of posterior malleolar fracture
through the posterolateral approach. Operative indications and timing of
weight bearing are still in discussion.
Conclusion Knowing whether ankle instability occurs and the proper
methods to diagnose, evaluate and operate can help manage the fracture.
Further biomechanical research is required on ankle stability and
clinical study to compare various treatment methods.
Malleolar ankle fractures are commonly encountered in orthopedic
trauma practice, the overall United States average was 4.2 ankle fractures
per 1000 Medicare enrollees.1 In 1822, Cooper was the first who described
a fracture of the ankle involving the posterior malleolus. In 1932,
Henderson defined the posterior malleolus as “the anatomic prominence
formed by the posterior inferior margin of the articulating surface of
the tibia” and was the first to use the term trimalleolar fracture.
Posterior malleolus fractures (PMF) can be detected in various types
of ankle fractures: trimalleolar fractures of which the incidence is about
14.2%;1 the isolated fractures of the posterolateral tibial lip
(Volkmann's triangle) which are rare with an estimated incidence of
0.5%-1%;1-3 posterior malleolar fractures associated with a tibial shaft
fracture of which the incidence is 1%-25% but still seems to be
underestimated.2,3
Posterior
malleolus
fractures
can
lead
to
incongruity
and
cartilaginous damage and thus posttraumatic arthritis, and have a
significantly worse functional outcome.4 However, how to evaluate the
ankle stability has not been exactly known; the proper measurements to
evaluate the posterior malleolar fractures are controversial; no
universal consensus has been reached on the best method to reduce and
stabilize the posterior tibial malleolus. This review give a brief
introduction of biomechanical evaluation, diagnose, classification and
surgical treatment of posterior malleolar fractures.
Biomechanical Evaluation of Posterior Malleolar Fractures
Roles of structures to ankle stability
The significant role of the lateral supporting structures is demonstrated
by many cadaver studies. It has been confirmed that if the fibula is stable
in an anatomic position, no posterior talar subluxation would happen even
with fragments consisting of approximately 30%-50% of the articular
margin.5 The internal supporting structures may be unimportant, as the
disruption of the deltoid ligament would not appear to alter contact area.6
Ankle stability depends substantially on the distribution of load, which
is called the mechanism of ankle stabilization by redistribution of
articular contact stress. When bearing load, the stresses were mainly
distributed to the second and third central quadrants of the talotibial
interface.7 When fragments exist, this load pattern is altered. However,
there is no increase in contact stresses near the articular incongruity,
but a shift in the location of the contact stresses to a more anterior
and medial location following the fracture,8-10 which may be determined by
the articular geometry.10 A review of the literature suggests the medial
and lateral constraints of the ankle rather than the articular surfaces
provide the majority of ankle stability.11
Impact of posterior malleolar fracture to ankle stability
The main task is to determine which fragment size of the posterior
malleolus would lead to instability. Two patterns are used for the
osteotomy cuts of the distal end of the tibia. Macko et al recommended
the pattern that the lateral point of the cut corresponds to one-fourth,
one-third, and one-half of the distance from the posterior to the anterior
margin.12 Using this pattern, fragments smaller than 25% would not lead
to ankle instability. Raasch et al used the cross-sectional pattern of
the ankle at the level of the maximum anteroposterior dimension and
conclude that after removal of 30 percent of the articular surface,
significant posterior translation of the talus occurred, which is
consistent with another study.6,8
Posterior malleolus fractures lead to ankle instability and thus
posttraumatic arthritis in clinical practice, which was confirmed in
follow-up clinical studies of 6.9 and 13 years respectively.9，13 A cartilage
biosynthetic transduction and injury characteristic is sensitive to
changes in contact stress rates. It is not the peak pressure, but the
changes of the center of stress leading to cartilage bearing significantly
higher contact stresses, that plays a large role in posttraumatic
arthritis development.11 Incongruity-associated changes in contact stress
rates and incongruity-associated instability events may be important
pathomechanical determinants of post-traumatic arthritis,14 but the exact
pathomechanical cause of posttraumatic arthritis is unclear.
Diagnose and classification of Posterior Malleolar Fractures
Evaluation methods and classification
Conventional plain radiography is still necessary in the primary
diagnosis and the measurement, and the fracture of the dorsal tibial
margin is best seen in the standard lateral view,15 but some unmarked
fragments could not be demonstrated. An external-rotation lateral view
(the average angle is 50 degrees) of the ankle may diagnose the fragments
16
effectively. The fragment size is conventionally measured on the lateral
X-ray of the ankle joint: the length of the involved articular surface
of the fragment divided by the length of the collective distal tibial
articular surface (including the articular surface of the fragment).13
Using a curved ruler to measure the arc of the articular surface may be
more accurate.17 However, the fracture lines appear to be highly variable
and lack of regulation. The posterior malleolar fragment can range in size
from a small extra-articular fragment to one comprising more than 40% of
the articular surface of the tibia,18 thus making it hard to evaluate.
CT scan provides a good visualization of the fracture. Preoperative using
of CT is justified, because it can detect the greatly varied fracture lines
that X-ray cannot distinguish.18 Plain films of the tibia may underestimate
the size of the fragment and the amount of the joint surface affected,7
making patients delay the operation thus leading a serious clinical
consequences, but mostly overrates the size of the fragment, which is
unreliable in assessing the posterior fragment size. In addition,
intraexaminer variability is high by using lateral radiograph,19
indicating a poor repeatability. CT-scan is emphasized on the diagnosing
and measurement.
Posterior malleolar fractures can be detected in: posteromedial fracture
fragments in type A and posterolateral fracture fragments in type B and
C of the Danis-Weber system; supination external rotation type Ⅲ-Ⅳ
lesion(SEⅢ-Ⅳ) and pronationin external rotation type Ⅳ lesion (PEⅣ)
in the Lauge Hansen classification system. Both of the two classifications
do not evaluate the severity of fracture and they are not prognostic.
Stability-based ankle fracture classification system can be practical.20,21
Haraguchi et al18 based on the orientation of the fracture line and
classified the posterior malleolus fractures: the posterolateral-oblique
type (67%), the medial-extension type (19%), and the small-shell type
(14%).
Tibia shaft fractures associated with posterior malleolar fractures
Tibia shaft fractures, typically spiral low-energy fractures of distal
third of the tibia, are often associated with occult posterior malleolar
fractures with a high undetected rate. The posterior malleolar fractures
may be overlooked while addressing more obvious and painful tibial shaft
fractures and is not well-detected. Stuermer et al
22
suggested that added
attention should be paid to the ankle with the following criteria such
as the indirect trauma with a rotation component or pronationeversion
trauma, spiral fracture of the tibia in the distal third, the tibial shaft
fracture associated with fracture of the fibula in the proximal third
or
an intact fibula. These indications can be a clue to diagnose, but not
enough to recognize the majority of theses combined injuries, therefore
the radiographic examination becomes indispensable.
The diagnose methods of tibia shaft fractures associated with posterior
malleolar fractures have been in discussion. X-ray is mandatory but being
suspected, especially in cases of low-energy distal tibial diaphyseal
fractures,2 its undetected rate can be 44%-68%（a prognostic study
included）.23 The three separate radiographic views (the anteriorposterior,
the mortise, and the lateral views) are recommended to help diagnose this
fracture pattern.22 A "communication line" from plain radiograph, which
connects the medial inferior apex of the spiral tibia fracture line and
the posterior superior apex of the posterior malleolar fracture, may be
a useful diagnostic clue.24 CT scan is recommended to be routinely
performed in clinical practice while MRI may be a compensative method.
Preoperative using of CT scan may prompt fracture stabilization25 and
identify the type of posterior malleolar fractures.23
Surgical treatment of Posterior Malleolar Fractures
Operative indications
Operative indications for surgical treatment of posterior malleolar
fractures are not currently well defined. Most orthopedic surgeons
consider a posterior malleolar fracture fragment larger than 25% to 33%
of the articular surface of the plafond or remaining displaced >2mm after
fibular reduction an operative indication, with which the ankle is
rendered unstable.7,18,26,27 In a recent meta-analysis, no consensus was found
in the literature regarding which fragment sizes of posterior malleolar
fractures should be fixed.11 Harper’s cadaver study has shown that if the
fibula is stable in an anatomic position, no posterior talar subluxation
would happen and posterior malleolar fractures need not to be fixed.5 The
fragments smaller than 25% may need not to be fixed when reduced
acceptably,13,28 While Langenhuijsen found that anatomic reduction should
be achieved when the fragments larger than 10% of the tibial articular
surface (the method did not always mean internal fixation, the mechanism
of ligamentotaxis could work).9
Most avulsion fractures can be treated non-operatively with success.
However, taking into account the biomechanics of the syndesmosis, some
scholars recommend the fixation of all posterior malleolar fragments
(only prospective study, Level II evidence).26 This may because of the
significant role of syndesmotic reduction contributing to functional
outcome29 and superior syndesmotic stability may be obtained by fixation
of the posterior malleolus rather than by using a trans-syndesmotic screw
fixation. Even minimal displacement may lead to post traumatic
arthritis,12 suggesting that anatomic reduction of all the displaced
posterior malleolus fractures can prevent posterior talar subluxation and
restore articular congruency to minimize posttraumatic osteoarthritis
and improves the prognosis of trimalleolar fractures.30 However, a
retrospective research has shown that the syndesmotic fixation has no
influence on functional outcome.20 Conservative treatment is needed for
the isolated posterior malleolar fractures. The satisfactory long-term
outcome were asserted31 and notably, for osteoarthritis, 95% patients had
no signs (excellent) or osteophytes (good), suggesting a low risk of
developing osteoarthritis.
Surgical approaches
Different approaches have been described for fixation of the posterior
malleolus: the medial approach, posteromedial approach and
posterolateral approach and so on. Many factors such as the type of
posterior malleolus fracture, ankle stability, and the height of the
fibular fracture line should be considered to choose the best approach.32
The most important factor to consider is the location of the fracture
fragment because of the deep position difficult to reveal and easy
rotation of posterior malleolus.
The medial approach is suitable for the medial fragment. Approximately
20% of the posterior malleolar fracture lines (type II fractures according
to the Haraguchi classification system) extend into the medial
malleolus.18 The medial side can be exposed but the long medial incision
requires extensive soft tissue stripping of the fracture fragments.
Besides, the posterior location of tarsal tunnel makes tarsal tunnel easy
to irritate and makes posterior to anterior screws difficult to be placed.
The fixing of the medial side of fragment is not stable and displacement
may occur during screwing. The posteromedial approach is suitable for the
large posteromedial-biased fragment which allows fixation of the posterior
and medial malleoli from the same incision.33,34 The skin incision follows
the posteromedial border of the distal tibia and medial malleolus and
continues in line with the tibialis posterior tendon toward the
talonavicular joint. A retrospective study demonstrated the satisfactory
short- and mid-term clinical results of this technique.34 However, this
approach has limited visualization of the posterior malleolus fragment,
an additional posterolateral approach may be required if the posterior
malleolus is split in two parts.
Interest has been growing in obtaining direct reduction and fixation of
the posterior malleolus using a posterolateral approach, which allows
good visualization and stable fixation of the posterior malleolus, and
many studies demonstrated the satisfactory clinical outcomes using this
approach.35-38 The longitudinal skin incision is made in the interval
between the posterior border of the fibula and the lateral border of the
Achilles tendon, which allows for simultaneous reduction and fixation of
the lateral malleolus through the same skin incision, and fracture is
revealed between the peroneus brevi and flexor hallucis longus muscles.
This approach provides the good visualization and reduction.36
Alternative surgical techniques
The majority of posterior malleolus fractures are avulsion fractures,
therefore most fractures reducing spontaneously after the fibular
fracture is reduced. The method of fixation of the posterior malleolus
was traditionally from the anterior aspect by using indirect reduction
and an anteroposterior screw, relying on the attachment of the ligament
to reduce posterior malleolus, which is supported by a recent study which
confirmed that almost all the posterior malleolar fractures were attached
to an intact posterior inferior tibiofibular ligament,29 but this type of
reduction cannot always ensure adequate articular reduction.
Debate arises regarding the best treatment. Questionnaires have shown
that trauma-trained surgeons were significantly more likely to choose
antiglide plate fixation compared to screw-only fixation and new
techniques such as direct exposure and plating of the posterior malleolus
are chosen more frequently than traditional method.27 A biomechanical and
clinical study has shown that screw-only fixation(two screws) are enough
to supply the stability for some small fragments involve only 1/4 of the
posterior articular facet; but for the fractures involve more than 1/4
facet, the plate fixation supplies more stable fixation and is superior
to simply screws.35 Bioabsorbable screws fixation is also suitable.36 The
buttress plate maintains reduction, prevents superior migration of
fragment,37 and can be placed in the intermuscular plane through the
posterolateral approach thus causing less irritation. The excessively
large or crushed fragment can be fixed by screw in combination with the
support plate, and external fixation or traction can be used. Chronic
displacement of the posterior malleolus fragment can be gradually reduced
with Taylor spatial frame,40 which can minimize the soft tissue dissection.
Relationship between posterior malleolus fracture and syndesmotic
injuries
With a small or large posterior malleolus fracture, the syndesmosis can
be reduced accurately using a clamp, although it can be obliquely
malreduced or slightly compressed.41 Then the syndesmotic injury can be
fixed by standard trans-syndesmotic fixation, which has a high rate of
syndesmotic malreduction (about 52%),42 or open posterior malleolus
fixation when the posteroinferior tibiofibular ligament is intact. Now
the advantages of posterior malleolus fixation have been justified.31,43,44
Gardner et al45 discovered that fixation of the posterior malleolus was
biomechanically superior to syndesmotic screw fixation in a cadaver study,
while Miller et al compared the functional outcomes (FAOS scores, which
is similar among groups) of three groups with open posterior malleolus
fixation, locked syndesmotic screws and combined fixation, and suggested
that syndesmotic fixation through the posterior malleolus at least
equivalent to syndesmotic screw.26 This may because the short duration
outcomes of Miller’s follow-up (mean, 15 months) did not fully
demonstrate the advantages.
Postoperative management and prognosis
Protected weight bearing may be started immediately. Harager K’s study
acquired satisfactory outcomes of patients who took weight-bearing from
3 weeks, to full weight-bearing after 6 weeks,43 and he recommended
immediate weight-bearing after surgery, even in the elderly, but the trail
is not randomized and prospective. The early weight bearing could
facilitate recovery and recommended utilizing it, but some scholars found
minimal benefit from early weight bearing in the first few weeks after
surgery.44,46 Walking cast, crutches and functional brace are needed to help
weight bearing; the functional brace may provide superior results over
plaster.44
Posterior malleolus fracture may indicate unstable ankle resulting from
high energy, and it seems to result in worse outcomes.30,47 A study compared
the outcomes of unstable fractures with or without posterior malleolar
fragment and found significant differences at the first year, definitely
in pain status and function, but mostly attenuated at the second year,
no significant difference in the complication rates and radiographic
outcomes.47
DISCUSSION
Biomechanical evaluation of posterior malleolar fractures is to find a
proper assessment of ankle stability, which is the foundation of therapy.
Ankle stability largely depends on the medial and lateral structures,
especially the fibular acting as the primary factor of ankle stability
and the correct distribution of load, which is consistent with the
excessive internal rotation caused by posterior malleolar fractures
without the supporting effect of fibula.48 Therefore, we should restore
this lateral constraints and the articular congruity.
Plain radiographic measurement is effective but does not accurately
reflect the real status of ankle, making plenty of malreduced syndesmoses
(about 69%) undetected.42 It is difficult to found occult posterior
malleolar fragment by x-ray examination, and the various types of fracture
lines make a generally accepted position hard to be made to best
demonstrate all the fracture lines. Unlike the inconsistent and
unreliable plain radiograph, CT scan does not have images overlapping,
two-dimensional imaging and could be a useful tool to detect the occult
fragments when associated with tibial shaft fractures, which is justified
by many studies.24,28,49
Traditional operative indications are being challenged now. Because the
fragment size cannot represent the ankle stability, factors such as
stability other than fragment size most impact surgical indications. In
some cases, satisfactory outcomes of fracture fragment larger than 25%
are achieved without an internal fixation,13,17 which means that even large
posterior fragments do not have to be fixed. A stability-test performed
using intraoperative fluoroscopic images may help decide whether to
operate on the fragment smaller than 25 % of the articular surface.50
Questionnaires have shown that fragment size still affected treatment
decisions and significant variation existed regarding the operative
indications of posterior malleolar ankle fracture. 27
The posterolateral approach is more frequently used. Fragments can obtain
direct exposure, reduction and fixation using a, which is safe, effective,
stable but invasive. The hardware with the posterolateral approach is deep
in the ankle, with good soft tissue coverage (under the muscle tissue
rather than the skin), thus making wound dehiscence will not lead to
disastrous complications. This approach is safer, though more invasive
than other approaches, leading to good results with few local
complications.51 The complications such as a slightly higher rate of
noninfected healing complications,52 wound infection (4.4%) and
reoperation (12.5%)53 should be noticed. The managing sequence is
posterior malleolus, fibula, and then medial malleolus described by Helmy
N et al and Irwin T A et al.54,55 Compared with the conventional lateral
approach, several characters should be noticed: more invasive; difficult
36
to fix the medial malleolus; complications.
Therefore, the
posterolateral approach is suitable for displaced fractures that involve
more than 30% of the distal articular tibial surface and that continue
to be displaced more than 2 mm after closed reduction of the ankle.
The treatment of syndesmotic injury still remains a matter of debate.
Posterior malleolar reconstruction is more accurate and more stable than
syndesmotic screw fixation, but even with attention to detail, reduction
sometimes remains imprecise.56 When posterior malleolus avulsion
fractures involved, reduction and fixation of the fragment can eliminate
the need for syndesmosis transfixation to fix the syndesmosis. Patients
who use a syndesmotic screw may undergo additional fixation of the
posterior fragment, so it seemed that 16-36% of syndesmotic screws may
be unnecessary（a retrospective cohort study included）.29,57 The syndesmotic
screw may be an injury to the posterior tibial blood vessels and nerve,
while the potential stress riser formation, and precludes early weight
bearing are also the disadvantages.
Excellent outcomes needs the stable fixation.58,59 Early weight bearing can
be adopted after the first postoperative week, if the posterior fragment
was fixed through a posterolateral or posteromedial approach, because the
posterior ankle joint surface remained unloaded when bearing load in an
experimental study.7 The plaster cast should be made to maintain the ankle
in neutral position and protect the posterior malleolus from axial load.
CONCLUSION
Experimental and clinical studies have shown the advances such as the role
of CT scan in detecting occult fracture, the advantage of plate fixation
using a posterolateral approach and so on, but debates such as ankle
stability and operative indications still need further research.
Acknowledgements
This work was supported by Projects in the Guangzhou Science & Technology
Program(2012Y2-00023).
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