Posterior Malleolus Fracture with Dislocation

A 38 year old presents to the Emergency Dept with a history of significant trauma to the ankle , there is minimal swelling, deformity is present, there is only minimal soft tissue injury(Tscherne grade 1), and no signs of distal ischemia. She has been admitted within 3 hours after injury. There are no comorbidities. What would be your plan of management?

The Posterior Malleolus Fracture with Ankle Dislocation:

• The distal tibiofibular syndesmotic complex is composed of the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous Ligament
• PITFL provides majority of syndesmotic stability. In general when the posterior malleolus is fractured, the syndesomosis is restored upon fixation of the posterior malleolus.( Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG: Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 2010;468(4):1129- 1135.)
• Posterior malleolar fractures can occur with any form of rotational ankle injuries like supination, pronation, external rotation, abduction
• The authors of a recent systematic review of the topic were unable to recommend evidenced-based guidelines for addressing posterior malleolar fractures, primarily based on the lack of standardization of functional outcomes used in the studies(van den Bekerom MP, Haverkamp D, Kloen P: Biomechanical and clinical evaluation of posterior malleolar fractures: A systematic review of the literature. J Trauma 2009;66(1):279-284.)
• The fragment size(more than 25% size) and joint dislocation should be considered while fixing the posterior malleolus

  

• The posterior malleolar fragment is usually a posterolateral fragment
• Recent authors have used a posterolateral approach to address the Posterior malleolar fragment and the fibula fracture in a single incision utilising the interval between the flexor halluces longus and the Peroneal tendons(Forberger J, Sabandal PV, Dietrich M, Gralla J, Lattmann T, Platz A: Posterolateral approach to the displaced posterior malleolus: Functional outcome and local morbidity. Foot Ankle Int 2009;30(4):309-314.)
• Debate exists on which fracture needs to be fixed first. The fixation of fibula will restore length and reduce the post malleolar fragment, but this may interfere with visualisation of the posterior malleolar fracture line on the lateral radiographic image.
• Antiglide plate or screws can be used for fixation
• There is a paucity of evidence based recommendations and outcome studies in the treatment of posterior malleolar fractures.
• In this case we reduced the dislocation in the Emergency OR within 30 minutes after admission to the hospital, and since the swelling was minimal and the soft tissues were Tschenre grade I ,we proceeded with internal fixation. We followed the technique described by Forberger using a posterolateral approach, the fibular length was restored and the posterior malleolus was fixed with a cancellous screw in posterolateral to anteromedial direction. The medial malleolus was fixed using screws via percutaneous stab incisions. The syndesmosis reduced spontaneously as observed by Miller et al..