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Archives of Orthopaedic and Trauma Surgery

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01-04-2015 | Trauma Surgery

Anatomy and classification of the posterior tibial fragment in ankle fractures

Authors: Jan Bartoníček, Stefan Rammelt, Karel Kostlivý, Václav Vaněček, Daniel Klika, Ivo Trešl

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 4/2015

Abstract

Introduction

The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort.

Materials and methods

One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19–83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients.

Results

We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments).

Conclusion

It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.

Chaput V (1907) Les fractures malléolaires du cou-de-pied et les accidents du travail. Masson, Paris

Bartoníček J (2004) Avulsed posterior edge of tibia—Earle’s or Volkmann’s triangle? J. Bone Joint Surg 86-B:746–750CrossRef

Felsenreich F (1931) Untersuchung über die Pathologie des sogenannten Volkmannschen Dreiecks neben Richtlinien moderner Behandlung schwerer Luxationsfrakturen des oberen Sprunggelenkes. Arch Orthop Unfall-Chir 29:491–529CrossRef

Lauge-Hansen N (1948) Fractures of the ankle. Arch Surg 56:259–317CrossRef

Nelson MC, Jensen NK (1940) The treatment of trimalleolar fractures of the ankle. Surg Gynecol Obstet 71:509–514

Weber BG (1966) Die Verletzungen des oberen Sprunggelenkes. Huber, Bern, p 102

Harper MC (1990) Talar shift. The stabilizing role of the medial, lateral and posterior ankle structures. Clin Orthop Rel Res 250:177–183

Karachalios T, Roidis N, Karoutis D, Bargiotas K, Karachalios GG (2001) Trimalleolar fracture with a double fragment of the posterior malleolus: a case report and modified operative approach to internal fixation. Foot Ankle Int 22:144–149PubMed

Weber M, Ganz R (2003) Malunion following trimalleolar fracture with posterolateral subluxation of the talus—reconstruction including the posterior malleolus. Foot Ankle Int 24:338–344PubMed

10.

Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD (2004) Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma 18:271–278CrossRefPubMed

11.

Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG (2010) Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 468:1129–1135CrossRefPubMedCentralPubMed

12.

Heim D, Niederhauser K, Simbray N (2010) The Volkmann dogma: a retrospective, long-term, single-center study. Eur J Trauma Emerg Surg 36:515–519CrossRef

13.

Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE (2011) Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int 32:385–393CrossRefPubMed

14.

Zenker H, Nerlich M (1982) Prognostic aspects in operated ankle fractures. Arch Orthop Trauma Surg 100:237–241CrossRefPubMed

15.

Jaskulka RA, Ittner G, Schedl R (1989) Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 29:1565–1570CrossRefPubMed

16.

Tejwani NC, Pahk B, Kenneth AE (2010) Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma 69:666–669CrossRefPubMed

17.

Rammelt S, Marti RK, Zwipp H (2013) Joint-preserving osteotomy of malunited ankle and pilon fractures. Unfallchirurg 116:789–796CrossRefPubMed

18.

van den Bekerom MPJ, Haverkamp D, Kloen P (2009) Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma 66:279–284CrossRefPubMed

19.

Rammelt S, Heim D, Hofbauer LC, Grass R, Zwipp H (2011) Problems and controversies in the treatment of ankle fractures. Unfallchirurg 114:847–860CrossRefPubMed

20.

Streubel PN, McCormick JJ, Gardner MJ (2011) The posterior malleolus: should it be fixed and why? Curr Orthop Prax 22:17–24CrossRef

21.

Bartoníček J (2003) Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat 25:379–386CrossRefPubMed

22.

Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA (1998) Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma 12:328–331

23.

Ebraheim NA, Mekhail AO, Haman SP (1999) External rotation-lateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int 20:379–383CrossRefPubMed

24.

Büchler L, Tannast M, Bonel HM, Weber M (2009) Reliability of radiologic assessment of the fracture anatomy at posterior tibial plafond in malleolar fractures. J Orthop Trauma 23:208–212CrossRefPubMed

25.

Friedburg H, Hendrich V, Wimmer B, Riede UN (1983) Computertomographie bei komplexen Sprunggelenksfrakturen. Radiologie 23:421–425

26.

Magid D, Michelson JD, Ney DR, Fishman EK (1990) Adult ankle fractures: comparison of plain films and interactive two- and three dimensional CT scans. Am J Radiol 154:1017–1023

27.

Haraguchi N, Haruyama H, Toga H, Kato F (2006) Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 88-A:1085–1092CrossRef

28.

Klammer G, Kadakia AR, Joos DA, Seybld JD, Espinosa N (2013) Posterior pilon fractures: a retrospective case series and proposed classification system. Foot Ankle Int 34:189–199CrossRefPubMed

29.

Yao L, Zhang W, Yang G, Zhu Y, Zhai Q, Luo C (2014) Morphologic characteristics of the posterior malleolar fragment: a 3-D computer tomography based study. Arch Orthop Trauma Surg 134:389–394CrossRefPubMed

30.

Chen DW, Bing L, Yang YF, Yu GR (2013) Posterior pilon fractures. Foot Ankle Int 34:766–767CrossRefPubMed

31.

Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I. Anatomical studies. Acta Orthop Scand 50:217–223CrossRefPubMed

32.

Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. II. Clinical studies. Acta Orthop Scand 50:223–236

33.

Jehlička D, Bartoníček J, Svatoš F, Dobiáš J (2002) Fracture-dislocations of the ankle in adults. Part I: epidemiological evaluation of one-year group of patients. Acta Chir Orthop Tramatol Čech 69:243–247

34.

Weber M (2004) Trimalleolar fractures with impaction of the posteromedial tibial plafond: implications for talar stability. Foot Ankle Int 25:716–727PubMed

35.

Xu H, Zhang D, Fu Z, Wang T, Zhang P, Jiang B, Shen H, Wang G, Wang G, Wu X (2012) A retrospective study of posterior malleolus fractures. Int Orthop 36:1929–1936CrossRefPubMedCentralPubMed

36.

Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG (2006) Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Rel Res 447:165–171CrossRef

37.

Müller ME, Nazarian S, Koch P, Schatzker J (1987) The comprehensive classification of fractures of long bones. Springer, Berlin, pp 180–191

38.

Müller ME, Allgöwer M, Schneider R, Willeneger H (eds) (1991) Manual der Osteosynthese, 3rd edn. Berlin, Springer, pp 595–612

39.

Heim U (1982) Indikation und Technik der Stabilisierung des hinteren Kantendreiecks nach Volkmann ber Malleolarfrakturen. Unfallheilkunde 85:388–394PubMed

40.

Heim U (1989) Trimalleoar fractures: late results after fixation of the posterior fragment. Orthopedics 12:1053–1059PubMed

Title: Anatomy and classification of the posterior tibial fragment in ankle fractures
Authors: Jan Bartoníček
Stefan Rammelt
Karel Kostlivý
Václav Vaněček
Daniel Klika
Ivo Trešl
Publication date: 01-04-2015
Publisher: Springer Berlin Heidelberg
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 4/2015
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-015-2171-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Anatomy and classification of the posterior tibial fragment in ankle fractures

Abstract

Introduction

Materials and methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Introduction

Materials and methods

Results

Conclusion

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