SLR - August 2021 - Elizabeth Oh

Posterior Malleolar Fractures: A Critical Analysis Review

Reference: Rammelt, Stefan, and Jan Bartonicek. “Posterior Malleolar Fractures.” JBJS, 2020,

Level of Evidence: Level IV, Retrospective Case Series 

Scientific Literature Review 

Reviewed By: Elizabeth Oh, DPM
Residency Program: University of Pittsburgh Medical Center, Mercy Hospital - Pittsburgh, PA

Podiatric Relevance: Posterior malleolar fractures involving the posterior rim of the distal tibia occur in 50 percent of all malleolar fractures. The presence of a posterior tibial fracture has been associated with poor prognosis. In recent literature, there have been a steady rise in studies revolving around posterior malleolar fractures with no consensus on best treatment. Advanced imaging such as computed tomography has assisted with an individualized approach. Posterior malleolar fractures are common with SER and PER ankle fractures.

Methods: The articles for this review were gathered by searching multiple databases focusing on complications, outcomes from surgical approaches, and identifying any risk factors associated with poor prognosis from 2002-2020. The purpose of this analysis is to organize updated information for optimal management of posterior malleolar fractures. 

Results: The authors found that with posterolateral approach there was an association with superficial wound infections in 5 percent of reported cases, deep wound infections requiring revision surgery involved 1 percent of reported cases, and neuropraxia involving the sural nerve was present in 4 percent of cases. Complications involving oblique lateral approach with posterior screw fixation with lateral plating of fibula had similar wound infection and sural nerve injury ranging from 0-4 percent in reported studies. There was a 42 percent incidence of post-operative malalignment of the posterior malleolar fragment >2 millimeters involving the articular surface after indirect reduction and percutaneous screw fixation. Direct fixation with posterior approaches has significantly less malalignment compared to the indirect approach. Open reduction and direct posterior to anterior screw of the PITFL avulsions reduce the mal-reduction rate of the fibula in its incisura by 4.5-fold when compared to closed reduction and syndesmotic screw. One third of the patients report post traumatic osteoarthritis with posterior malleolar fractures. Salvage options in symptomatic patients include ankle arthrodesis and/or ankle replacements. A systematic review reports that the size of the posterior fragment is inferior to the degree of displacement and articular incongruity (including tibiotalar subluxation) in determining prognosis, in addition to the degree of fibular reduction into its incisura. 

Conclusions: Ankle fractures with posterior malleolar fractures have a potential negative impact on outcomes and prognosis. Computed tomography is essential in treatment planning to assess degree of displacement, incisura involvement and presence of joint impaction. A direct approach reduces the rate of mal-reduction as compared to indirect/closed reduction/percutaneous approach. Independent risk factor of an intra articular step off >2 millimeters is associated with poor outcomes including post traumatic arthritis regardless of fragment size.

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