Orthopedics Presentation

1. Posterior Malleolus Fractures of Ankle
An evolution in the management of
fractures of ankles
BJJ- Nov- 2017
Dr. A. Sai Anurag
2nd Yr PG
OCNA- Jan 2017

2. Introduction
• About 2/3rd of ankle fractures are isolated malleolar fractures, 1/4th are bi-
malleolar and remaining 7th are tri-malleolar.
• Isolated posterior malleolar fractures (PMF) are rare, with an estimated
incidence of 0.5% - 1% of ankle fractures.
• An understanding of posterior malleolus anatomy, the ligamentous attachments,
and its contribution to ankle congruity and stability is critical in determining the
appropriate treatment.

3. Anatomy
• The ankle is a complex hinge joint composed of articulations among the tibial
plafond, distal fibula and the talus.
• The ankle joint is saddle shaped and derives its stability from a combination of
bony and ligamentous structures.
• The posterior malleolus is an anatomic prominence formed by the posterior
inferior margin of the articulating surface of the tibia.
• The distal tibial articular surface (plafond) is concave in AP plane, but convex
in lateral plane.

4. • The plafond is wider anteriorly to allow for congruency with the
wedge shaped talus, providing intrinsic stability, especially in weight-
bearing.
• The talar dome is trapezoidal, with anterior aspect 2.5 mm wider
than the posterior talus.
• The medial malleolus articulates with the medial facet of the talus
and divides into anterior colliculus and posterior colliculus, which
serve as attachments for the superficial and deep deltoid ligaments,
respectively.

5. • The syndesmotic ligament complex exists between the distal tibia
and fibula resisting axial, rotational and translational forces to
maintain the structural integrity of the mortise (Plafond together
with medial and lateral malleoli)
• It is composed of four ligaments-
1. Anterior-Inferior tibio fibular ligament (AITFL)
2. Posterior-Inferior tibio fibular ligament (PITFL)
3. Inferior-Transverse tibio fibular ligament
4. Interosseous Ligament (IOL)

7. • 42% of Syndesmotic ability is provided by the PITFL, 35% by AITFL,
22% by IOL
• Since the PITFL extends from posterior malleolus to the posterior
tubercle of fibula, PMFs challenged the structural integrity of
posterior syndesmotic ligaments and may produce syndesmotic
disruption.

8. • The deltoid ligament provides support to medial aspect of the ankle.
• It is separated into superficial and deep components.
• Superficial Portion: It is composed of three ligaments that originate on anterior
colliculus
1. Naviculotibial ligament: This suspends the spring ligament and prevents inward
displacement of talar head.
2. Tibiocalcaneal ligament: This prevents valgus displacement.
3. Superficial Talotibial ligament: Most prominent of the three.

9. • Deep Portion: Deep tibio talar originates on the intercollicular groove and
the posterior colliculus of the distal tibia and inserts on entire non articular
medial surface of the talus.
• Its fibers are transversely oriented; it is the primary medial stabilizer
against lateral displacement of the talus.

10. • Fibular Collateral Ligament is made up of three ligaments that provide lateral
support to the ankle:
1. Anterior Talofibular Ligament- Weakest of lateral ligaments.
2. Posterior Talofibular Ligament- Strongest of lateral ligaments.
3. Calcaneal Fibular Ligament- Stabilizes subtalar joint and limits inversion.

11. BIOMECHANICS
• The normal ROM of ankle in dorsiflexion is 30◦ & in plantarflexion is 45◦
• For normal gait minimum of 10◦ dorsiflexion & 20◦ plantarflexion are
required.
• The axis of flexion of ankle runs between distal aspect of the medial &
lateral malleoli, which is externally rotated 20◦ compared with the knee
axis.
• Disruption of the syndesmotic ligaments may result in decreased tibio
fibular overlap.

12. Clinical Evaluation
• Patients may have a variable presentation, ranging from a limp to
nonambulatory in significant pain & discomfort, with swelling, tenderness,
and variable deformity.
• Neurvascular status should be carefully documented & compared with the
contralateral side.
• The extent of soft tissue injury should be evaluated, with particular
attention to possible open injuries & blistering.
• The quality of surrounding tissues should also be noted.

13. • The entire length of the fibula should be palpated for tenderness
because associated fibular fractures may be found proximally as high as
the proximal tibiofibular articulation.
• A “squeeze test” may be performed approximately 5 cm proximal to the
intermalleolar axis to assess possible syndesmotic injury.
• A dislocated ankle should be reduced & splinted immediately (before
radiographs if clinically evident) to prevent pressure or impaction injuries
to the talar dome & to preserve neurovascular integrity.

14. Radiographic Assessment
• X-Ray: AP view, lateral view and mortise.
• Identification of posterior malleolar injury best evaluated on lateral view.
• Computed tomography (CT) scan should be performed for all PMFs to
evaluate fragment size, comminution, articular impaction, and syndesmotic
disruption.
• Preoperative CT changed the surgeon’s treatment and operative plan

15. AP View
• Tibiofibula overlap of < 10 mm is abnormal & implies syndesmotic
injury.
• Tibiofibula clearspace of > 5 mm is abnormal & implies syndesmotic
injury.
• Talar tilt: A difference in width of the medial & lateral aspects of the
superior joint space of > 2 mm is abnormal & indicates medial or
lateral disruption.

16. Lateral View
• The dome of the talus should be centered under the tibia &
congruous with the tibial plafond.
• Posterior tibial tuberosity fractures can be identified, as well as
direction of fibular injury.
• Avulsion fractures of the talus by the anterior capsule may be
identified.
• Anterior or posterior translation of the fibula in relation to the tibia in
comparison to the opposite uninjured side is indicative of a
syndesmotic injury.

17. Mortise View
• This is taken with the foot in 15 to 20 of internal rotation to offset
the intermalleolar axis.
• A medial clear space > 4 to 5 mm is abnormal & indicates lateral talar
shift.
• Talocrural angle: The angle subtended between the intermalleolar
line & a line parallel to the distal tibial articular surface should be
between 8 and 15
• The ankle should be within 2 to 3 of the uninjured ankle.
• Tibiofibular overlap < 1 cm indicates syndesmotic disruption.
• Talar shift > 1 mm is abnormal.

18. HARAGUCHI CLASSIFICATION
• Based on preoperative CT scans, 3 types -
• Type 1 : Posterolateral-oblique type (67%)
• Type 2 : Medial-Extension type (19%)
• Type 3 : Small-shell fragment (14%)
• There is a continuous spectrum of type 3
to type1 fractures & type 2 is a separate
pattern

19. BARTONICEK & COLLEAGUES CLASSIFICATION
• 5 fractures patterns-
• Type 1 –Extraincisural fragment with an intact fibular notch
• Type 2- Posterolateral fragment extending into the fibular notch
• Type 3- Posteromedial 2 part fragment involving the medial malleolus
• Type 4- Large posterolateral triangular fragment
• Type 5- Nonclassified, irregular, osteoporotic fragments

20. MANAGEMENT OF POSTERIOR MALLEOLAR
FRACTURES
• Principles of treatment:
• Isolated, nondisplaced PMF’s should be treated conservatively
• Surgical criteria for the reduction and fixation of the PMF should be based on
the concept of restoring ankle joint structural integrity.
• Posteromedial or posterolateral surgical approaches can be used to address
this injury
• The posterior malleolus should be fixed first as the fibular metalwork will
obstruct the imaging, although the fibula maybe reduced and held before
fixing the posterior malleolus fracture.

21. • If articular congruity is not achieved, this is an indication for reduction and
fixation of the posterior fragment.
• In cases in which small osteochondral fragments may interfere with anatomic
reduction or become loose bodies, or articular impaction is recognized.
• Then it is advisable to approach the fracture site and address this before
attempting reduction and fixation of lateral malleolus fracture.
• In addition, assessing ankle joint syndesmotic and rotatory instability is of
paramount importance and is a major component of surgical indication.

22. Surgical Approach & Technique:
1. Posteromedial Approach:
• Patient is positioned prone under General Anaesthesia
• Skin incision is made midway between the posterior margin of medial
malleolus and medial border of Achilles tendon, which is the interval
between the angiosomes of posterior and anterior tibial arteries

23. • The fascia overlying the neurovascular bundle is divided and the neurovascular
structures are mobilized
• This allows development of areas on either side of the neurovascular bundle
to facilitate fixation of the individual fragments of the fracture.
• The flexor hallucis longus is mobilized to access the posterior fragment and an
arthrotomy may be performed

24. • Anteriorly, the retinaculum is divided over the tendons.
• A window is made and the best approach to the posteromedial fragment is
determined from the CT Scans.
• This is often between the flexor digitorum longus & tibialis posterior
• The fragments are provisionally reduced & held with Kirschner wires.

25. • The reduction is verified by ensuring reduction at the cortical apex of the
fracture, and fluoroscopically.
• The fragments are stabilized with small fragment buttress plates and/or
cortical lag screws.

26. • Posterolateral Approach: Allows good visualization of the posterolateral
malleolar fragment & concomitant treatment of the fibula fracture is easily
performed.
• Skin Incision: Mid way between lateral border of Achilles tendon & the
posterior border of the fibula.
• During superficial dissection the sural nerve must be identified & protected.
• The deep dissection develops the plane between flexor hallucis tendon and
peroneals.
• Once the FHL belly is elevated from the fibula^& lateral tibia, retracted
medially, the posterolateral fragment is visualized.

27. • While exposing & manipulating the fragment great care should be taken to
preserve the PITFL.
• Reduction is facilitated with dorsiflexion of the ankle.
• A ball spike or bone tamp aids in achieving reduction & the temporary fixation
with kirschner wire can be performed.
• Once the fragment is properly reduced a slightly under contoured plate can be
used in an anti-glide technique.
• Although first fixating the fibula restores length and facilitates the posterior
malleolar reduction, the fibular plate can hinder adequate visualization of the
posterior malleolar reduction with fluoroscopy.

29. JOURNAL

30. • Unstable fractures of the ankle have a poorer outcome if the posterior
malleolus is involved.
• Traditional teaching subsequently advocated fixation of posterior malleolar
fragments based on their size when assessed on a lateral radiograph.
• As the indication for fixations have changed, the use of the posterolateral
approach in the interval between the peroneal tendons & flexor hallucis
longus when fixing the posterior malleolar fragments has gained in popularity.

31. AIM
• A Haraguchi type II posterior malleolar fracture with posteromedial extension
is considered to be a distinct entity.
• The instability of this type of fracture is due to its involvement of the
posterior colliculus & therefore the deep deltoid ligament.
• These fractures cannot be fixed using a standard posterolateral approach.
• So the aim is to describe the fixation of Haraguchi type II posterior malleolar
fractures using a posteromedial approach to the ankle that allows fixation of
the characteristic fragments commonly seen with this injury.

33. Patients & Methods
• 15 patients were identified who had undergone fixation Haraguchi type II
posterior malleolar fractures through a posteromedial approach.
• The indications of fixation included instability demonstrated by initial
posterior dislocation or residual posterior subluxation on radiographs,
articular incongruence or disruption to the syndesmosis or deltoid
ligament as assessed on CT.
• 5 patients underwent initial temporary spanning external fixation, when
it was not possible to hold the talus congruently beneath the tibia in a
plaster & the soft tissues were too swollen to allow immediate internal
fixation.

34. RESULTS
• OLERUD & MOLANDER Score:

35. • The median Olerud & Molander score recorded after 29 months in 14
patients was 72 (IQR 70 to 75), representing a good functional outcome.
• The reduction of the posterior malleolar fragment was anatomical in 10
patients.
• There was a median step or gap of 1.2 mm (IQR 0.9 to 1.85) in the remaining
five.
• One patient had parasthaesiae of the medial forefoot which resolved after
three months.
• One patient required removal of metal work because of discomfort.

36. DISCUSSION
• The study shows that posteromedial approach can be saved used to address
the management of these complex injuries.
• The only complication was a transient sensory nerve palsy.
• Plain radiographs alone are insufficient to assess the posterior malleolar
fragment.
• Fixation of the posterior malleolus improves the stability of the joint & is at
least as good as transyndesmotic fixation.
• A buttress plate provides better stability & less displacement irrespective of
the size of the fragment.

37. • A concern when using a posteromedial approach is that it involves
exposure of the neurovascular bundle & care must be taken to mobilize
& protect this throughout the procedure.
• A preoperative CT scan for all posterior malleolar fractures to assess the
morphology of the fracture accurately & consideration of a
posteromedial approach in those fractures that extent into the medial
malleolus.

38. Outcomes and Prognosis
• Trimalleolar fractures have worse prognosis compared with
unimalleolar or bimalleolar fractures.
• The presence of posterior tibial component has an adverse effect on
the outcome.
• Posterior malleolus fragment size should not be used as the sole
criterion for the decision of surgical intervention.
• Langenhuijsen & Colleagues showed that achieving joint congruity with
or without fixation was a significant factor in prognosis.

39. • Significantly better long term results are seen in posterior malleolar
fragments involving greater than 5 % of the articular surface treated
surgically, compared with those treated non surgically.
• More advanced post traumatic arthritis was co-related with larger
fragment size.
• Drijfhout Van Hooff & Colleagues found more radio graphic
osteoarthritis in patients with medium and large posterior fragments
than those with small fragments.

40. SUMMARY
• CT Scan is imperative for the evaluation of fragment size, comminution,
articular impaction & syndesmotic disruption.
• Fragment size should not be the only factor to dictate treatment.
• Focus on restoring articular congruity, correcting posterior talar translation,
addressing articular impaction, removing osteochondral debris & achieving
syndesmotic stability.
• The posteromedial approach to the ankle is the safest when fixing a
Haraguchi type II fracture configuration.

41. Thank you!