Review Article

Posterior Malleolus Fracture

Abstract
Todd A. Irwin, MD John Lien, MD Anish R. Kadakia, MD

Posterior malleolus fractures are a common component of ankle fractures. The morphology is variable; these fractures range from small posterolateral avulsion injuries to large displaced fracture fragments. The integrity of the posterior malleolus and its ligamentous attachment is important for tibiotalar load transfer, posterior talar stability, and rotatory ankle stability. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benets, such as restoring articular congruity and rotatory ankle stability, as well as preventing posterior talar translation, but current indications are unclear. Fragment size as a percentage of the anteroposterior dimension of the articular surface is often cited as an indication for xation, although several factors may contribute to the decision, such as articular impaction, comminution, and syndesmotic stability. Outcome studies show that, in patients with ankle fractures, the presence of a posterior malleolus fracture negatively affects prognosis. Notable variability is evident in surgeon practice.

From the Department of Orthopaedic Surgery, Division of Foot and Ankle Surgery, University of Michigan, Ann Arbor, MI (Dr. Irwin), the Department of Orthopaedic Surgery, University of Michigan, Ann Arbor (Dr. Lien), and the Department of Orthopaedic Surgery, Northwestern University, Chicago, IL (Dr. Kadakia). Dr. Irwin or an immediate family member serves as a paid consultant to Smith & Nephew. Dr. Kadakia or an immediate family member serves as a paid consultant to Acumed LLC and Synthes. Neither Dr. Lien nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2013;21: 32-40 http://dx.doi.org/10.5435/ JAAOS-21-01-32 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

osterior malleolus fractures occur in 7% to 44% of all ankle fractures, most in the setting of rotational ankle fractures.1,2 Cooper3 first described the posterior malleolus fracture in the setting of a chronic ankle fracture-dislocation in 1822. In 1932, Henderson4 introduced the term trimalleolar ankle fracture. The trimalleolar ankle fracture with a displaced posterior malleolus fragment is distinguished from the tibial pilon fracture by the supra-articular metaphyseal involvement of the pilon, with varying degrees of articular impaction. The contributions of the posterior malleolus to the congruity of the ankle joint, as well as of its ligamentous attachments, are important factors to consider when determining appropriate management of trimalleolar ankle fractures. Posterior malleolus fractures are heterogeneous in

morphology, and no consensus currently exists regarding their optimal treatment.

Anatomy and Biomechanics

The ankle is a complex ginglymoid joint that is afforded stability through a combination of bony and ligamentous structures. In the sagittal plane, the tibial plafond is concave, with the posterior lip of the plafond extending distally; this forms the posterior malleolus, or Volkmann tubercle.5 The distal tibiofibular syndesmotic complex is composed of the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous ligament (Figure 1). The PITFL originates from the posterior malleolus and runs obliquely distally to its insertion on the posterior fibula. It is

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Figure 1

Clinical photograph of a cadaver dissection of the posterior ankle. Note the exor hallucis longus being retracted medially (thin arrow) and the peroneal tendons laterally (thick arrow). The posterior inferior tibiobular ligament (+) traverses distally in an oblique direction from the posterior malleolus to the bula.

composed of a superficial component and a deep component.6 OgilvieHarris et al7 performed a cadaver study demonstrating that the PITFL provides 42% of syndesmotic stability. This contribution to syndesmotic stability is disrupted when the posterior malleolus is fractured. In an unstable ankle, the loss of normal bony or ligamentous constraints allows the talus to move in a nonphysiologic manner. This may predispose the ankle to degenerative changes. Macko et al8 and Hartford et al9 created posterior malleolus osteotomies in cadaver models and demonstrated that, with increasing fragment size, there is decreased joint contact area and increased confluence and concentration of loads. At 33% fragment size, only 87% of contact area remained. These authors concluded that this decreased
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articular surface area may lead to increased peak stresses and higher rates of arthrosis, although peak stresses were not measured in either study. Fitzpatrick et al,10 however, showed that mean and peak contact stress magnitudes do not significantly increase with a simulated posterior malleolus fracture involving 50% of the joint. They demonstrated that the location of contact stress redistributes anteromedially during dynamic range of motion (ROM) and concluded that this increased load to areas of chondrocytes unaccustomed to such loading may contribute to posttraumatic arthrosis. Interestingly, there was no evidence of talar subluxation or instability during the ROM testing. Raasch et al11 further investigated the restraints to posterior instability of the ankle. They concluded that the fibula and AITFL function as the primary restraint to posterior translation of the talus because posterior subluxation of the talus in simulated fractures involving >30% of the posterior malleolus occurred only after disruption of the fibula and AITFL.

terolateral tibial fragment of varying size and medial extension (stage III). Stage IV indicates medial ankle injury, such as a medial malleolus fracture or a deltoid ligament rupture. In pronation-abduction injuries avulsions of the syndesmotic complex (stage II) and fibula fracture caused by the abduction force (stage III) also may produce posterior malleolus fractures.13 Combined rotational and axial load injuries may produce the posterior pilon variant, which is characterized by the presence of an additional posteromedial fragment, as well as comminution and marginal impaction.14 Occult posterior malleolus fractures are also commonly seen in distal spiral tibia fractures, particularly when there is an associated proximal fibula fracture.15

Radiographic Assessment
Standard ankle plain radiographs (ie, AP, mortise, lateral) are indicated for initial evaluation. Posterior talar subluxation can be identified on the lateral radiograph (Figure 2). According to Bchler et al,16 the size of the posterolateral fragment can be accurately and reliably estimated as a percentage of the articular surface in the sagittal diameter of the tibial plafond. However, these authors found plain radiographs to have poor reliability and accuracy in determining the extent of comminution and impaction of the posterior fracture. In contrast, Ferries et al17 found that radiographs poorly assessed posterior fragment size compared with CT. Ebraheim et al18 suggested that a 50 external rotation lateral radiograph coplanar with the fracture plane bests visualizes the fracture; however, the orientation of the posterior malleolus fracture line is highly variable. In the posterior pilon variant, a double contour sign may be appreciated on the AP radio-

Mechanism of Injury
Posterior malleolus fractures occur most commonly in the setting of a rotational ankle fracture, although they do occur rarely in isolation.12 The Lauge-Hansen system classifies fracture patterns by identifying the mechanism of injury with the first word describing the position of the foot and the second word describing the direction of the force.13 The staging of each pattern is described as a progression of injury around the ankle from a specific starting point. For example, after the AITFL (stage I) and fibula (stage II) fail in supination-external rotation injuries, the PITFL can be strained or disrupted, or it can avulse, with a pos-

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graph, indicating the presence of a posteromedial fracture fragment19 (Figure 3). The authors recommend that CT be performed for all fractures involving the posterior malleolus to better evaluate fragment size, articular impaction, comminution, and a possible concomitant anterior disruption of the syndesmosis.20

tures are small shell-shaped avulsion fragments at the posterior lip of the tibial plafond (Figure 4). Although the classification does identify morphologic patterns of injury, guidelines for surgical decision-making were beyond the
Figure 2

scope of the study by Haraguchi et al,21 and reproducibility has not been clinically validated.
Figure 3

Classication
Although many historical studies frequently classify posterior malleolus fractures based on fragment size, controversy exists regarding how fracture size correlates to management. Haraguchi et al21 explored the pathoanatomy of the posterior malleolus fracture. They observed three types of fracture patterns based on CT analysis. Posterolateral oblique (type I) fractures have a wedgeshaped fragment involving the posterolateral tibial plafond. Transverse medial-extension (type II) fractures contain a fracture line extending from the fibular notch to the medial malleolus. Small-shell (type III) fracFigure 4

Lateral radiograph demonstrating posterior talar subluxation with an associated large posterior malleolus fracture.

AP radiograph demonstrating the double contour sign (arrow) proximal to the medial malleolus, indicating the presence of a posterior malleolus fracture with posteromedial extension.

Axial CT scans demonstrating the three types of posterior malleolus fracture pattern, based on the CT analysis of Haraguchi et al.21 A, Type I, posterolateral oblique wedge-shaped fragment. B, Type II, fracture line extends from the bular notch to the medial malleolus. C, Type III, shell-shaped avulsion fragments at the posterior lip of the tibial plafond.

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Management Clinical Decision Making

Nonsurgical management is reserved for isolated, nondisplaced posterior malleolus fractures and evaluated on CT. Multiple factors must be considered in deciding whether to address the posterior malleolus fracture surgically. 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.22 Historically, the size of the fragment has been a major determining factor. Several authors recommend internal fixation when the posterior fragment comprises >25% to 33% of the tibial plafond.23,24 This threshold was based on the biomechanical studies discussed earlier that involved changes in contact area and stability.8,9 There were several retrospective reviews1,23,25-28 and one historical text.29 However, high-level data in the literature are insufficient to support the use of this number as a threshold. Articular congruity and posterior talar subluxation are also important factors to consider. With anatomic reduction of the lateral malleolus fracture, the posterior malleolus often is reduced via ligamentotaxis of the PITFL. If there is residual displacement of the posterior fragment, this should be corrected, as is recommended for most articular fractures. Often small osteochondral fracture fragments may be interposed in the fracture site, preventing adequate reduction. Removal of these loose bodies, or reduction if the fragment is large enough, will aid in restoring articular congruity. If there is persistent posterior subluxation despite stabilization of the lateral ankle, then the posterior malleolus fracture should
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be surgically fixed to provide a bony restraint against translation. Another important factor is the role served by the posterior malleolus and PITFL in rotatory ankle stability. Gardner et al30 reported a syndesmotic malreduction rate after transsyndesmotic screw fixation of 52% on postoperative CT evaluation. Of the 13 fractures with a malreduced syndesmosis, 5 had associated posterior malleolus fractures, and 10 (77%) had an increased distance from the fibula to the posterior facet of the incisura. Gardner et al20 performed MRI studies on 15 fractures involving the posterior malleolus; all showed an intact PITFL. In the same study, a cadaver model demonstrated that posterior malleolus fixation restored 70% of syndesmotic stiffness compared with 40% with syndesmotic screw fixation.20 The authors suggest that anatomic reduction and fixation of a posterior malleolus fracture will restore syndesmotic stability by restoring the length of the intact PITFL and by preventing posterior translation of the fibula. Clinical decision-making is highly variable. A recent survey reported that only 29% of surgeons use a fragment-size threshold of 25% as an indication for surgical management.31 For 56% of surgeons, indication for fixation depends on stability and other factors. Nevertheless, case scenarios demonstrated that size did play a role in decision making: a 50% articular fragment was indicated for fixation by 97% of respondents, whereas a 10% articular fragment would be addressed by only 9%. Medium-sized fragments (approximately 20% of the articular surface), as well as comminution and posteromedial extension, provided more varied responses, with approximately 45% of respondents stating that these factors indicated the need for surgical fixation.31

Surgical Technique
Several approaches for fixation of the posterior malleolus have been described. The presence of medial and/or lateral malleolus fractures must first be considered because these help determine patient positioning. Options for obtaining reduction of the posterior fragment include indirect reduction by ligamentotaxis of the PITFL with anatomic fibular reduction and direct visualization through an open approach. With indirect reduction, the most common fixation approach utilizes anterior-to-posterior screws placed under fluoroscopy. Because most posterior malleolus fractures are oblique, thus creating a posterolateral fragment, attention to screw orientation is important to obtain adequate purchase in the fragment. Alternatively, posterior-toanterior screws or an antiglide plate can be placed through the fibular incision by dissecting posterior to the fibula, retracting the peroneal tendons posteriorly, and dissecting the flexor hallucis longus (FHL) off the tibia. For direct visualization of the posterior malleolus fragment, a posterolateral approach using the FHL and peroneal muscle interval has gained in popularity.32 Usually performed with the patient prone, both the posterior malleolus and fibula fracture can be addressed through this approach. After the FHL is swept medially, the posterior fragment is visualized. The fragment should be mobilized from medial to lateral and proximal to distal to preserve the PITFL attachment and clean the ankle joint of any osteochondral debris. Fixation is achieved with lag screws or a buttress plate. The plate can facilitate achieving an anatomic reduction by using an antiglide technique (Figure 5). Fixation of the plate at the apex of the fracture can compress the fracture and reduce the posterior and superiorly displaced fragment. The fib-

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Figure 5

Intraoperative photographs depicting xation of a posterior malleolus fracture through a posterolateral approach. A, Posterolateral incision with the patient in the prone position. Note the expected course of the sural nerve (dashed line). B, The exor hallucis longusperoneal muscle interval. The arrow identies intact bers of the posterior inferior tibiobular ligament. C, Displaced posterior malleolus and bula. D, Fixation with a one-third tubular plate. Note the screw at the apex of the fracture, which is creating an antiglide effect.

ula fracture is addressed by sweeping the peroneal tendons medially or laterally and plating the fibula posteriorly. Debate exists as to which fracture should be addressed first. Reducing and fixing the posterior malleolus before the fibula allows adequate visualization of the reduction on fluoroscopy because otherwise the fibular plate often interferes with the fracture line on the lateral view (Figure 6). However, reducing and fixing the fibula first allows the surgeon to restore length, which of-

ten helps in reducing the posterior malleolus fragment. The sural nerve should be identified and protected during this approach; in a cadaver study, it was shown to enter the field in 83% of posterolateral approaches.33 In the posterior pilon variant, adding a posteromedial approach can aid in achieving fixation of the medial extension of the posterior fragment.34 If this is required, care should be taken to avoid placing hardware in the posterior tibial tendon groove. How-

ever, the posteromedial fragment usually can be accessed through aggressive retraction of the FHL, thus minimizing the need for a second posteromedial incision.

Postoperative Management
Cast or splint immobilization is provided in the immediate postoperative period. In general, protected weight bearing or no weight bearing is rec-

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ommended for 6 to 8 weeks postoperatively.25,35 A systematic review of early mobilization of surgically treated ankle fractures concluded that early ROM is associated with a quicker return to work and improved ROM at 12 weeks, although surgery is also associated with an increased wound infection rate.36 There is no evidence of improved outcome scores or ROM at 1 year postoperatively. One study supported early weight bearing in a neutral ankle position after fixation of the posterior malleolus.25 However, there is at present insufficient evidence to support early weight bearing in these fractures. We prefer a period of 6 weeks of no weight bearing, followed by 3 to 6 weeks of weight bearing in boot immobilization. Early ROM is allowed at 2 weeks if incisions are healed.

Figure 6

Lateral uoroscopic images demonstrating initial reduction using wires for temporary xation (A), and the nal xation (B). Note in panel B the bular plate blocking visualization of the posterior malleolus fracture reduction.

Outcomes
Published literature on ankle fractures involving the posterior malleolus is limited by the lack of standardization in examining functional outcomes, relatively small patient populations, and varied treatment protocols by the investigators. This has led to a systematic review declaring that no consensus exists regarding the minimal size of a posterior malleolus fracture fragment requiring fixation.22 Authors of another systematic review who examined long-term outcome in all surgically managed ankle fractures found that only 58% of ankle fractures involving the posterior malleolus had a good or excellent result at 4 years postinjury.37 Several studies show that trimalleolar fractures have worse outcomes than do unimalleolar or bimalleolar fractures, and that, in general, patients with larger posterior malleolar fragments (>25%) have inferior reJanuary 2013, Vol 21, No 1

sults compared to those with smaller fragments.1,23,35 However, Jaskulka et al1 noted that even small posterior tibial rim fractures may be associated with a poorer prognosis. Tejwani et al38 similarly observed significantly worse clinical outcome scores at 1 year in patients with posterior malleolus fractures; however, at 2 years, this difference was no longer significant. The question remains as to whether there is a minimal fragment size that requires surgical fixation. Several authors recommend surgical fixation of posterior malleolus fractures involving >25% of the articular surface.23,24 Tejwani et al38 reported a trend toward improved function in fractures managed with surgical fixation of the posterior malleolus; importantly, the average size of the fixed fragment was 25.2% of the articular surface compared with 16.1% in the non-fixed fragments. In contrast, Harper and Hardin26 compared results with and without inter-

nal fixation of fractures involving >25% of the tibial plafond and found no significant difference in clinical results between the two groups. These authors were able to achieve satisfactory reduction of the posterior fragment with reduction of the fibula. Authors of two studies found evidence that a 25% posterior malleolar size threshold should not be used as a criterion for surgical intervention. Langenhuijsen et al27 concluded that joint congruity should be achieved for all posterior malleolus fractures involving 10% of the articular surface, with or without internal fixation. Surgical fixation was reserved for fragments involving 10% of the articular surface that remained displaced despite adequate medial and lateral malleolus reduction. Similarly, Jaskulka et al1 reported significantly better long-term results in posterior fragments involving >5% of the articular surface treated surgically compared with those treated nonsur-

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Figure 7

Case example of posterior malleolus fracture. Preoperative AP radiograph (A) and sagittal CT scan (B) of a pronationabduction ankle fracture-dislocation. C, Intraoperative photograph with the elevator in the posterior malleolus fracture line. Note the intact posterior inferior tibiobular ligament. Postoperative mortise (D) and lateral (E) radiographs taken 3 months after denitive xation.

gically. Heim28 recommended surgical fixation of all posterior malleolar fragments except posterior lip avulsions, based on a long-term radiographic review of 45 patients. Two studies have examined the effect fixation of the posterior malleolus fracture has on syndesmotic stability. Miller et al39 evaluated postoperative CT scans in three groups: patients treated with posterior malleolus reduction and fixation

regardless of fragment size, those managed with syndesmotic screws only, and those treated with a combination of both methods. The authors found that posterior malleolar reconstruction more accurately restored the syndesmotic articulation than did syndesmotic screw fixation. A functional outcome study performed at the same institution that compared similar patient groups reported equivalent outcomes in patients man-

aged with syndesmotic stabilization through fixation of the posterior malleolus compared with syndesmotic screws.40 However, in this study, all posterior malleolus fractures were fixed surgically. No study to date has been performed comparing surgical fixation of the posterior malleolus to the use of syndesmotic screws alone in the presence of a posterior malleolus fracture.

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Authors Preferred Treatment

In general, we do not follow a strict size threshold for management of the posterior fragment. Posterior lip avulsion fractures, as well as small, completely nondisplaced posterior fragments, are usually managed conservatively. In the case of any significant displacement, regardless of fragment size, we treat the posterior malleolus fracture with open reduction and internal fixation through a posterolateral approach with the patient in the prone position. The posterior malleolus fragment is addressed first with a buttress or antiglide plate, followed by posterior plating of the fibula. The medial malleolus fragment can then be fixed if present (Figure 7). Syndesmotic stability should be checked using stress fluoroscopy after fracture fixation. In our experience, syndesmotic screws are rarely required when the posterior malleolus is fixed primarily; however, this should be evaluated with the preoperative CT to determine the integrity of the anterior tibiofibular joint. We agree with Miller et al40 and Gardner et al20 that fixation of the posterior malleolus can significantly improve rotatory ankle stability.

variability in management within the orthopaedic community is evident, not only regarding the decision to address the fracture surgically, but also in approach and fixation technique. Although 25% articular involvement historically has been used as a threshold for fixation, surgeons now recognize that other factors must be considered. With increased utilization of CT scans, the true size of the fragment and the presence of articular impaction with associated intra-articular fragments have become more evident, which can aid in the decision-making process. In particular, some studies suggest that fixation of the posterior malleolus to reduce persistent fragment displacement, regardless of size, as well as to restore syndesmotic stability, may lead to improved outcomes. Although results are varied, it is clear that ankle fractures with posterior malleolus involvement tend to have worse clinical outcomes.

and on Fractures of the Joints. London, UK, Longman, Hurst, Reese, Orme and Brown, E. Cox and Son, 1822, pp 238357. 4. Henderson MS: Trimalleolar fracture of the ankle. Surg Clin North Am 1932;12: 864. Sarrafian SK, Kelikian AS: Osteology, in Kelikian AS, Sarrafian S, eds: Sarrafians Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2011, pp 40-48. Sarrafian SK, Kelikian AS: Syndesmology, in Kelikian AS, Sarrafian S, eds: Sarrafians Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2011, pp 163-166. Ogilvie-Harris DJ, Reed SC, Hedman TP: Disruption of the ankle syndesmosis: Biomechanical study of the ligamentous restraints. Arthroscopy 1994;10(5):558560. Macko VW, Matthews LS, Zwirkoski P, Goldstein SA: The joint-contact area of the ankle: The contribution of the posterior malleolus. J Bone Joint Surg Am 1991;73(3):347-351. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB: Tibiotalar contact area: Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res 1995;(320):182-187. Fitzpatrick DC, Otto JK, McKinley TO, Marsh JL, Brown TD: Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma 2004;18(5):271-278. Raasch WG, Larkin JJ, Draganich LF: Assessment of the posterior malleolus as a restraint to posterior subluxation of the ankle. J Bone Joint Surg Am 1992; 74(8):1201-1206. Neumaier Probst E, Maas R, Meenen NM: Isolated fracture of the posterolateral tibial lip (Volkmanns triangle). Acta Radiol 1997;38(3):359-362. Lauge-Hansen N: Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950;60(5): 957-985. Karachalios T, Roidis N, Karoutis D, Bargiotas K, Karachalios GG: Trimalleolar fracture with a double fragment of the posterior malleolus: A case report and modified operative approach to internal fixation. Foot Ankle Int 2001;22(2):144-149. Boraiah S, Gardner MJ, Helfet DL, Lorich DG: High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res 2008;466(7):1692-1698.

5.

6.

7.

8.

9.

References
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 36 is a level I study. References 15, 35, and 40 are level II studies. References 1, 20, 24, and 36-39 are level III studies. References 4, 12, 14, 1619, 23, 25-28, and 32 are level IV studies. Reference 31 is level V expert opinion. References printed in bold type are those published within the past 5 years.
1. Jaskulka RA, Ittner G, Schedl R: Fractures of the posterior tibial margin: Their role in the prognosis of malleolar fractures. J Trauma 1989;29(11):15651570. Court-Brown CM, McBirnie J, Wilson G: Adult ankle fractures: An increasing problem? Acta Orthop Scand 1998; 69(1):43-47. Cooper AP: A Treatise on Dislocations,

10.

11.

12.

Summary
Posterior malleolar fractures are heterogeneous in morphology, and CT is useful to define fracture patterns. Fixation of posterior malleolus fractures in the setting of rotational ankle injuries has certain benefits, including restoring articular congruity, increasing rotatory ankle stability, and providing a bony restraint against posterior translation. Current indications however are unclear because they are based on retrospective level III and IV studies. Great
January 2013, Vol 21, No 1

13.

14.

2.

15.

3.

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16. Bchler L, Tannast M, Bonel HM, Weber M: Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma 2009;23(3): 208-212. Ferries JS, DeCoster TA, Firoozbakhsh KK, Garcia JF, Miller RA: Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma 1994;8(4):328-331. Ebraheim NA, Mekhail AO, Haman SP: External rotation-lateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int 1999;20(6): 379-383. Weber M: Trimalleolar fractures with impaction of the posteromedial tibial plafond: Implications for talar stability. Foot Ankle Int 2004;25(10):716-727. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG: Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165-171. Haraguchi N, Haruyama H, Toga H, Kato F: Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 2006;88(5):1085-1092. 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):279284. McDaniel WJ, Wilson FC: Trimalleolar fractures of the ankle: An end result study. Clin Orthop Relat Res 1977; (122):37-45. De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR: Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005;44(3): 211-217. 25. Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E: Early weight bearing after posterior malleolar fractures: An experimental and prospective clinical study. J Foot Ankle Surg 2003;42(2):99-104. Harper MC, Hardin G: Posterior malleolar fractures of the ankle associated with external rotationabduction injuries: Results with and without internal fixation. J Bone Joint Surg Am 1988;70(9):1348-1356. Langenhuijsen JF, Heetveld MJ, Ultee JM, Steller EP, Butzelaar RM: Results of ankle fractures with involvement of the posterior tibial margin. J Trauma 2002; 53(1):55-60. Heim UF: Trimalleolar fractures: Late results after fixation of the posterior fragment. Orthopedics 1989;12(8):10531059. McLaughlin HL: Trauma. Philadelphia, PA, Saunders, 1960, p 357. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG: Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 2006; 27(10):788-792. Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM: Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int 2011;32(4): 385-393. 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 38. 2009;30(4):309-314. 33. Jowett AJ, Sheikh FT, Carare RO, Goodwin MI: Location of the sural nerve during posterolateral approach to the ankle. Foot Ankle Int 2010;31(10):880883. Amorosa LF, Brown GD, Greisberg J: A surgical approach to posterior pilon fractures. J Orthop Trauma 2010;24(3): 188-193. Mingo-Robinet J, Lpez-Durn L, Galeote JE, Martinez-Cervell C: Ankle fractures with posterior malleolar fragment: Management and results. J Foot Ankle Surg 2011;50(2):141-145. Thomas G, Whalley H, Modi C: Early mobilization of operatively fixed ankle fractures: A systematic review. Foot Ankle Int 2009;30(7):666-674. Stufkens SA, van den Bekerom MP, Kerkhoffs GM, Hintermann B, van Dijk CN: Long-term outcome after 1822 operatively treated ankle fractures: A systematic review of the literature. Injury 2011;42(2):119-127. Tejwani NC, Pahk B, Egol KA: Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma 2010;69(3):666-669. Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG: Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int 2009;30(5):419-426. 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):11291135.

17.

34.

26.

18.

35.

27.

19.

36.

28.

20.

37.

29. 30.

21.

22.

39.

31.

23.

40.

32.

24.

40

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