Fracture of the lower leg with involvement of the posterior malleolus; a neglected combination?

doi:10.1016/0020-1383(88)90035-6

Injury

Volume 19, Issue 4, July 1988, Pages 241-243

https://doi.org/10.1016/0020-1383(88)90035-6 Get rights and content

Abstract

In 17 of 148 fractures of the leg (11.5 per cent) we found an isolated fracture of the posterior malleolus of the tibia as a sign of associated injury of the ankle joint. In two cases there was even disruption of the anterior syndesmosis. All fractures of the tibia were oblique and closed without severe soft tissue injury and caused by a rotational force with low energy. In fracture of the leg of this specific type a radiological examination of the ankle joint in search for a posterior malleolar fracture is needed. If present, instability of the distal tibiofibular joint must be excluded.

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There are more references available in the full text version of this article.

Cited by (38)

Incidence and risk factors of occult posterior malleolar fracture in patients with spiral distal tibial fracture: Reexamination and analysis
2022, Asian Journal of Surgery
To evaluate the incidence and risk factors for posterior malleolar fractures (PMFs) in patients with spiral distal tibial fractures (SDTFs).
In a retrospective study, 248 adults with SDTFs who underwent treatment were enrolled between November 2017 and May 2020. In a prospective study, we recruited 113 consecutive, skeletally mature patients with SDTFs who were identified from the trauma clinic of our hospital between June 2020 and May 2021. Radiographs and CT scans of the ankle region on the affected side were obtained to determine the presence of PMFs. If the CT scan was negative, additional MRI examination of the ankle was performed as a supplementary protocol in the prospective study. Univariate analysis and multivariate analysis were conducted to analyze the risk factors.
In the retrospective study, the incidence of PMFs associated with simple SDTFs was 74.0% (105/142), which was significantly lower than 90.8% (69/76) in the prospective study. Independent predictors of PMFs in patients with simple SDTFs identified by multivariate analysis in the retrospective study were age (OR = 1.07; P = 0.001) and external rotation of the proximal tibia (OR = 3.36; P = 0.027) and those in the prospective study were osteoporosis (OR = 0.04; P = 0.007) and spiral fibula fractures (OR = 16.05; P = 0.046).
This study reexamined the high incidence of concurrent PMFs. Additionally, ankle radiographs and CT scans were recommended for all simple SDTF patients. For simple SDTF patients with negative CT scans, especially those caused by external rotation of the proximal tibia, combined with nonosteoporotic or spiral fibula fractures, additional MRI examinations are recommended.
Distal tibial fractures treated with intramedullary nailing: management of associated posterior and medial malleolar injuries
2022, Injury
Articular tibial ankle injuries may occur in association with distal tibial fractures, especially in those characterized by spiral or oblique shape. These lesions are often misdiagnosed and overlooked with significant biomechanical and clinical consequences. The purpose of this study was to evaluate the outcomes of patients affected by posterior and medial malleolar ankle fractures associated with distal tibial fracture who underwent intramedullary nailing at a follow-up of 3 years. Furthermore authors wanted to highlight the correct sequence of diagnosis and fixation in these associated fracture patterns.
All treated patients between 2006 and 2016 (Group 1) were compared with a control group (Group 2) without ankle lesions. Demographic variables and data related to surgical procedure and hospitalization were documented and analyzed. X-rays and computed tomography before operation were reviewed to identify type of fracture; radiographs after surgery and at follow-up were respectively analyzed to study the quality of joint reduction and the development of osteoarthritis. Clinical outcomes were evaluated using OMAS and DRI scores.
Thirty-six patients were in group 1 and 36 in group 2. In group 1 longer operating time and hospitalization were documented. Quality of reduction in group 1 was always satisfactory. No signs of osteoartritis were detected at 3 years follow-up. The mean union time was 23.6 weeks for group 1 and 20,4 for group 2 (p=0.111). No differences in clinical scores were documented after 6 months. The full weight-bearing time was longer in group 1 (p=0.017).
Clinical results appeared similar. No osteoarthritis was documented in group 1 as consequence of good articular reduction that is better and more easily executable if malleolar ankle fractures are fixed before intramedullary nailing. In distal tibial fractures CT has always to be performed to recognize associated ankle lesions as it may modify the surgical plan, postoperative management and outcomes.
Determining your implant: Templating a nail for the distal tibia fracture
2022, Injury
Citation Excerpt :
The use of CT scans to evaluate for intra-articular pathology of the ankle joint should be strongly considered if not routine in these fractures (18,19). It is estimated that 10% to as high as 56% of distal tibia fractures have concomitant intra-articular ankle pathology [12–16]. These injuries are known to have high rates of Haraguchi type I and II fractures [17–19].
The goal of this article is to aid the orthopedic surgeon in determining whether an intra-medullary (IM) device for fixation of a distal tibia fracture is feasible. Using Computed Tomography (CT) scans of the fracture, this review demonstrates a simple way to determine whether two or even three distal interlocking screws are achievable in stable bone. Additionally, this paper offers a summary chart of commonly used tibial nails which can be used for planning purposes. Finally, a clinical summary of very distal tibial shaft fractures treated with IM fixation is provided.
The isolated posterior malleolar fracture and syndesmotic instability: A case report and review of the literature
2017, International Journal of Surgery Case Reports
Citation Excerpt :
Furthermore, these fractures are known injuries in parachute landings or as part of a pilon tibiale fracture [16]. They result from impression of the talus on the posterior edge of the distal tibia [20]. Besides other fractures, it should also be noted that ligamentous injuries can exist [5].
Ankle fractures are among the most common type of fractures in the lower extremity. A posterior malleolar fracture is frequently part of a more complex ankle fracture and only in rare cases it occurs as isolated injury. Posterior malleolar fractures often occur with associated injuries, such as a Maisonneuve fracture or with bi- or trimalleolar ligamentous injuries. Knowledge about these associated injuries is essential to prevent missed diagnoses. The aim of this article is to describe the isolated posterior malleolar fracture, the possible associated injuries, the diagnostic work-up and therapeutic consequences.
We present a case of a 26-year-old male patient who sustained an isolated posterior malleolar fracture with 4.5 years follow-up.
Isolated fractures of the posterior malleolus are uncommon injuries. Diagnosis, treatment and outcome can seldom be extracted from large series. However, several cases have been described in literature, which we have summarized.
This case report and literature review shows that isolated posterior malleolar fractures might occur as part of a more complex ankle injury, in combination with a fracture of the lower leg or after high energy trauma. Physicians should be aware of these associated injuries. Diagnostic work-up should include X-rays of the knee and lower leg and a CT scan of the ankle. If diagnosed and treated properly, isolated posterior malleolar fractures have a good long-term functional outcome.
Concomitant tibial shaft and posterior malleolar fractures can be readily diagnosed from plain radiographs: A retrospective study
2014, Journal of the Chinese Medical Association
Citation Excerpt :
By identifying fracture combinations, further displacement of PMF fragments, either intra-operatively during intra-medullary nailing5 or post-operatively due to inadequate protection, can be prevented. The incidence of concomitant tibial shaft fracture and PMF in our study was 8.3%, which is comparable to that in previous studies.1–4 A literature review of concomitant tibial shaft fracture and PMF is presented in Table 3.1–4
Concomitant tibial shaft and posterior malleolar fractures (PMFs) are often encountered in clinical settings. Plain films were reviewed for concomitant PMF, and fracture patterns were analyzed by focusing on the integrity of the fibula and the location of the fibular fracture.
A retrospective review of patients who presented with tibial shaft fractures between January 2005 and January 2010 was performed. Patients were included if they were at least 18 years of age and had a tibial diaphyseal fracture. Exclusion criteria were age less than 18 years, previous surgery on the same leg, and pathological fractures. Medical records were reviewed for information on injury mechanisms. Pre- and post-operative radiographs were analyzed for PMFs, tibial fracture pattern, fibular integrity, fibular fracture pattern, treatment type, and time to fracture union. Descriptive statistical tests were used.
Among 240 patients, there were 20 cases (15 male and 5 female) of concomitant PMF, all detected in lateral radiograph views. The incidence of PMF was 8.3%. Most patients had a motorcycle injury (n = 15, 75%). Distal tibia spiral fracture was the most common fracture pattern (85%) and there was no proximal tibia fracture (0%). Combined fibular fractures were found in 17 patients (85%). There were nine proximal fibular fractures (45%). Intact fibulas were found in three patients (15%). Only one PMF was treated with screw fixation. All PMFs showed radiographic evidence of healing within 5 months post-operatively.
We recommend careful radiographic examination to evaluate PMF, especially in patients with distal tibial spiral fractures combined with proximal fibular fractures or intact fibulas.
The "communication line" suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture
2012, European Journal of Radiology
Citation Excerpt :
Bostman reported a 0.6% incidence of concurrent ankle fractures with tibial fractures [1,2]. Van der Werken and Zeegers reported an 11.5% occurrence of isolated PMF in low-energy spiral tibia fractures [3]. Recent studies reported higher incidences ranging from 25% to 88% [4–6].
To demonstrate radiographical characteristics of the relationship between distal spiral tibial shaft fractures and associated occult posterior malleolar fractures (PMF) that confirmed by CT and MRI.
X-rays for a ninety-six patients with spiral tibia fracture and associated PMF were reviewed. All patients additionally had an ankle CT. Patients with a negative CT scans underwent an ankle MRI. Radiographic observations included fracture location, characteristics, and a presence of a fracture line between the two injuries.
The spiral tibia fracture line was contiguous with PMF in 89 of 96 cases after evaluation with the CT and MRI. The line connecting the two injuries, which occurs between the medial inferior apex of the spiral tibia fracture line and the posterior superior apex of the PMF was identified as the “communication line”. In 47 of the 89 conjunction fractures, the “communication line” was detectable preoperatively and in 12 cases postoperatively by anteroposterior radiograph. By using the CT and MRI scans, we found that no “communication line” was present in only 7 cases.
It is important to understand the nature of the association between distal spiral tibial shaft fractures and occult posterior malleolar fractures for optimal stabilization of the fracture and for appropriate rehabilitation. The “communication line” is a useful diagnostic clue for early recognition the occult PMF and alerts a closer evaluation of the lateral view and further CT examination.

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Fracture of the lower leg with involvement of the posterior malleolus; a neglected combination?

Abstract

Isolated fracture of the posterior tibial tubercle. Aetiologic and clinical features

Acta Chir. Scand.

Die Verletzung des oberen Sprunggelenkes als Begleitläsion indirekter Unterschenkelfrakturen

Z. Orthop.