In this article, we present how to treat posterior malleolar fractures , especially associated with syndesmosis injury by a case sharing. We also review the current concepts of posterior mallleolar fracture in ankle fracture by preoperative CT evaluation and surgical approach with modified PM approach.

1. Ankle Fracture
Posterior Malleolus Fracture
Chun-Hao Tsai,MD
中國醫藥大學 附設醫院
骨科部 副教授 蔡俊灝 醫師
Associate Professor
Department of Orthopedic Surgery, China Medical University Hospital,
Taichung, Taiwan, R.O.C.

2. •Gender: female
•Age:56
•Presenting Symptoms: painful deformity of left ankle
•Clinical History: traffic accident related
•Comorbidities : nil
•Other Consideration: nil

4. Fracture Pattern
• Axial Load
• Varus
• Valgus
• Sagittal Plane
• Anterior
• Posterior

7. Posterior
Malleolus
Fracture
Indication of ORIF
Choice of fixation method

8. Surgical goal
Fixation for Posterior malleolus
• Screw
• AP
• PA
• Plate
Surgical approach Posterior malleolus
• Posteromedial
• Modified posteromedial
• Posterolateral

10. • (I) Extraincisural fragment with
an intact fibular notch
• (II) Intraincisural posterolateral
fragment.
• (III) Intraincisural two-part
fragment involving the medial
malleolus
• (IV) Intraincisural large triangular
fragment.
Bartonicek and Rammelt
3D CT Classification

11. Posterolateral VS posteromedial Approach
FHL –Peroneal Tendon VS FHL-tibial nerve Interval
identification of the FHL

12. Modified posteromedial
Posteromedial Posterolateral
Modified
posteromedial
Strain on the flap (N) 21.5 16.8 7.0
Exposure 64% 40% 91%
{Assal, 2017 #64}
Flexor hallucis longus

13. Lateral Transmalleolar Approach and Miniscrews Fixation for
Displaced Posterolateral Fragments of Posterior Malleolus
Fractures
{Kim, 2015 #70}

14. ORIF for Posterior Malleolus Fracture
Antiglide plate fixation / Screw fixation
Bartonicek and
Rammelt type
Talus
Subluxation
%
Transverse
Fragment
%
Height
(mm)
Depth
(mm)
ORIF APPROACHES
Extraincisural 36 9 11.2 8.1 Non-op
Posterolateral 39 14 17.9 8.7 ν posterolateral
Two-part 59 24 29.1 12.7 ν
posterolateral and
posteromedial
Large triangular 85 29 37.4 18.1 ν posterolateral

15. Finite Element Analysis of the Three Different Posterior Malleolus Fixation
Strategies in Relation to Different Fracture Sizes:
AP screw <PA screw < posterior plate
Two AP lag screws, Two PA lag screws, Posterior plate
{Anwar, 2017 #66}
{OʼConnor, 2015 #68}

17. /p 6 Ms

18. Take home message
-Posterior malleolar Fractures
• Fix criteria
• no depend on the size
• but also the fragment position related to incisura
• Approach
• Modified posteromedial
• Posterior-medial or –lateral approach correspond to related malleolar
fracture
• Fix implants
• Antiglide plate better than screw