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Posterior Malleolar Fractures

A Critical Analysis Review

Stefan Rammelt, MD, PhD Abstract

» In patients with ankle fractures, the presence of a posterior malleolar
Jan Bartonı́ček, MD, PhD
fracture has a negative impact on the prognosis.

» Computed tomography (CT) scanning is essential for fracture

classification and treatment planning, as the indication for surgery
depends on the 3-dimensional fragment outline and displacement,
incisura involvement, and the presence of joint impaction.
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKbH4TTImqenVA5KvPVPZ0P55kGcPHfz7GVCB874XSNGUeMX0JIDfG4Y on 08/30/2020

» Anatomic reduction of a posterior malleolar fragment restores the

incisura, facilitating reduction of the distal part of the fibula, and it also
restores the integrity of the posterior portion of the syndesmosis,
reducing the need for additional syndesmotic stabilization.

» Direct open reduction and fixation of posterior malleolar fragments

from a posterior orientation is biomechanically more stable and
provides a more accurate reduction than does indirect reduction and
anterior-to-posterior screw fixation.

» Intra-articular step-off of $2 mm is an independent risk factor for an

inferior outcome and the development of posttraumatic arthritis,
irrespective of the fragment size.

F
ractures of the posterior rim of
the distal end of the tibia occur
in up to 50% of all malleolar
fractures1-4. They are referred to
as “posterior malleolar”5 or “posterior
pilon” fractures6. Fragmentation of the
posterior tibial rim regularly occurs in distal
tibial (pilon) fractures7,8, which is beyond
the scope of this review. The presence of a
posterior tibial fragment in malleolar frac-
tures has been associated with a less favor-
able prognosis1,9-13.
Earle, in 1828, first described a frac-
ture of the posterior rim of the distal
end of the tibia in an ankle fracture-
dislocation14,15. In the large body of Ger-
man literature, this fragment is commonly
referred to as the “Volkmann’sches
Dreieck” (Volkmann triangle)16,17.
Although von Volkmann18 only described
an anterolateral distal tibial fracture, this
term is still frequently used also in the
English-language literature15,19. The term
“malléole postérieure” (posterior malleo-
lus) was introduced in 1911 by Destot5. A
bimalleolar fracture in combination with a
posterior malleolar fracture was described
in 1836 by Adams20, after which Hen-
derson21, in 1932, introduced the term
“trimalleolar fracture.” The first reports on
screw fixation of the fractured posterior
tibial rim date back to the 1920s22,23.
Despite a steadily growing number of
studies, there is still no consensus on the
best treatment24-27. However, with more
frequent use of computed tomography
(CT) imaging recently, a better under-
standing of ankle fracture patterns has re-
sulted in a more individualized approach
to treatment28-31.

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JOURNAL OF BONE AND JOINT
SURGERY, INCORPORATED
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of the article, one or more of the authors checked “yes” to indicate that the author had a relevant
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JBJS REVIEWS 2020;8(8):e19.00207 · http://dx.doi.org/10.2106/JBJS.RVW.19.00207 1

 | Poster ior Malleolar Fract ures

Anatomy
The distal end of the tibia (tibial pilon
or plafond) has a concave articular
surface that transmits axial compression
forces24,32. It is sloped, with the posterior
malleolus projecting more distally than the
anterior rim33. The medial aspect of the
posterior malleolus is separated from
the medial malleolus by a retromalleolar
groove containing the posterior tibial ten-
don (Fig. 1). The lateral aspect of the
posterior malleolus forms the posterior
tibial tubercle and posterior part of the
fibular notch (incisura fibularis tibiae).
The posterior inferior tibiofibular
ligament (PITFL) consists of superior
oblique and inferior transverse parts24. It
provides 42% of the total strength of the
tibiofibular syndesmosis34. Jayatilaka
et al.35 found that the superficial PITFL
insertion area on the tibia in 10 cadaver
specimens was considerably greater than
the average area covered by the postero-
lateral and posteromedial malleolar frag-
ments in their clinical series of 80 patients
with posterior malleolar fractures. The
intermalleolar ligament (IML) and the
posterior talofibular ligament reinforce
the posterior joint capsule36.
Pathoanatomy and Classification
The first classifications of posterior
malleolar fractures were proposed
shortly after the introduction of
radiographs37,38. Nelson and Jensen, in
1940, classified posterior malleolar
fractures as “classical” when affecting
one-third or more of the articular sur-
face, and “minimal” when involving
less39. Because they saw inferior results
in 8 patients with classical type fractures
managed nonoperatively, they recom-
mended screw fixation for these frac-
tures, thus introducing the “one-third
rule,” which called for fixation of all
posterior malleolar fragments com-
prising one-third or more of the artic-
ular surface; it is still used by many
surgeons today40. The 1990 AO clas-
sification41 distinguished between
extra-articular (Type 1), small articular
(Type 2), and large articular posterior
malleolar fragments (Type 3).
Because the exact pathoanatomy of
posterior malleolar fractures cannot be
determined by radiographs alone,
present-day classifications are CT-
based. Weber distinguished between a
single, lateral posterior lip fragment and
2-part or multifragmentary fractures of
the entire posterior lip involving the
posterior colliculus of the medial
malleolus42.
Haraguchi et al. proposed 3 types
of posterior malleolar fractures on the
basis of an analysis of the axial CT scans
of 57 patients28: Type I, seen in 67% in
this series, represents a posterolateral
oblique fracture of the distal part of the
tibia resulting in a triangular fragment;
Type II (19%) represents a medial
extension fracture involving the poste-
rior part of the medial malleolus; and
Type III (14%) represents a shell frac-
ture of the posterior tibial cortex.
Our group previously analyzed
141 consecutive axial, sagittal, and cor-
onal CT images29. Posterior malleolar
fractures were classified as 4 basic pat-
terns, with special reference to incisura
involvement (Fig. 2): Type 1 (seen in
8%) represents an extraincisural frag-
ment; Type 2 (52%), a posterolateral
fragment; Type 3 (28%), a posterome-
dial, 2-part fragment similar to Har-
aguchi Type II; and Type 4 (9%), a
large, posterolateral triangular fragment
containing one-third to one-half of the
fibular notch of the tibia (Fig. 3). The
remaining 3% of the cases were classified
as Type 5, which involves an irregular
osteoporotic fracture that does not
match any of the other 4 basic patterns.
A similar classification was later pro-
posed by Mason et al.43. The transverse
area, height, and depth of the posterior
malleolar fragment and the percentage
of tibiotalar subluxation or dislocation
increase across the first 4 types of our
previously reported classification (Bar-
tonı́ček and Rammelt), suggesting that
the fracture types indeed represent a

Fig. 1
Figs. 1-A, 1-B, and 1-C Anatomy of the posterior malleolus and the posterior capsular complex of the ankle joint. 1 5 retromalleolar groove, 2 5
inferior horizontal part of the posterior inferior tibiofibular ligament (PITFL), 3 5 superior oblique part of the PITFL, 4 5 peroneal groove, 5 5 oblique
triangular facet of the posterolateral talar dome, 6 5 posterior talofibular ligament (PTFL), 7 5 calcaneofibular ligament, 8 5 fibular origin of the PTFL in
the malleolar fossa, 9 5 intermalleolar ligament (IML), and 10 5 common origin of the IML and PTFL. Fig. 1-A Posterior view with the intermalleolar
ligament and posterior capsule removed. Fig. 1-B View from below of the distal tibial articular surface. Fig. 1-C View from posterior with the highly
variable IML intact.

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Fig. 2
Graphic depiction of the CT-based classifica-
tion of posterior malleolar fractures according
to our previously described classification sys-
tem29. Type 5 is used to describe an irregular
(osteoporotic) fracture that does not fit into
any of these 4 patterns.
scale of increased injury severity and
ankle instability29.
The course of the fracture lines as
outlined in both the Haraguchi and the
Bartonı́ček and Rammelt classification is
reflected by the continuous spectrum of
posterolateral and posteromedial frac-
ture lines seen by Mangnus et al.44 when
summarizing the data of 45 patients
using a CT mapping technique. In
contrast to the AO41 and Heim45 clas-
sifications based on radiographs, we
previously29 did not observe any extra-
articular posterior malleolar fragments
starting superior to the joint surface and
exiting the posterior tibial cortex further
proximally.
The authors of several CT-based
studies29,42-44,46 detected a high per-
centage of fractures with depressed
intercalary fragments. Sultan et al.46
detected an intercalary fragment in 43%
of 247 posterior malleolar fractures. The
fragment was located posterolaterally in
64% of the cases, directly posteriorly in
19%, and posteromedially in 17%. The
AUGUST 2020 · VOLUME 8, ISSUE 8 · e19.00207
Poster ior Malleolar Fractures |
prevalence of an intercalary fragment tion of the articular surface4,46,52.
was 70% among Bartonı́ček and Ram- Haraguchi et al.28 used the trans-
melt Type-3 fractures, which was sig- malleolar line to distinguish posterior
nificantly higher than in the other 3 malleolar from posterior pilon fractures.
types (p , 0.05)46. In our previous work29, we used the line
In a CT analysis of 107 patients, connecting the center of the fibular
Yi et al.47 found supination-external notch and the intercollicular groove as
rotation (SER) injuries of the ankle to be the limit for posterior malleolar frac-
significantly associated with Bartonı́ček tures. Thus, when the posterior frag-
and Rammelt Type-2 posterior malleo- ment extends into the anterior colliculus
lar fractures and pronation-external of the medial malleolus or when it
rotation (PER) injuries of the ankle to be comprises .50% of the incisura, the
associated with Types 3 and 4 (p 5 injury is better classified as a partial pilon
0.02). Similarly, Zhang et al.48 found fracture.
that an increase in the Bartonı́ček and
Rammelt classification from Type 2 to Biomechanical Considerations
Type 4 was highly correlated with the Through its osseous configuration and
risk of displacing the posterior malleolar ligament attachments, the posterior
fragments associated with spiral distal malleolus is an important stabilizer of
tibial fractures when treated with intra- the ankle. The results from biome-
medullary tibial nailing as well as viola- chanical studies on cadaver specimens,
tion of the fragment by distal locking however, are inconsistent. Harper53
bolts (p , 0.015) and the incidence of a found no measurable effect on ankle
second fracture line in the posterior
stability through resection of up to 50%
malleolus (p 5 0.004). These findings of the posterior articular surface of the
were confirmed with CT fracture
mapping49. In Bosworth fracture-
dislocations, posterior dislocation of the
proximal fibular fragment was associated
with a Bartonı́ček and Rammelt Type-1
posterior malleolar fracture, while
incarceration of the proximal fibular
fragment between the posterior malleo-
lar fragment and the posterior part of the
tibia was observed exclusively in Types 2
and 350.
Posterior Malleolar or Posterior
Pilon Fractures?
The distinction between malleolar frac-
tures with posterior malleolar involve-
ment and partial (posterior) pilon
fractures is basically a matter of con-
vention29. Hansen6 described all poste-
rior malleolar fractures that occurred in
association with Weber B and C frac-
tures as “posterior pilon” fractures.
Others have termed fractures with either
large posterior malleolar fragments43 or Fig. 3
medial extension4,51,52 as “low-energy Three-dimensional CT images of Types 1 to 4
pilon,” “posterior pilon variant,” or posterior malleolar fractures according to our
“posterior pilon” fractures. The latter previously described classification system29.
Type 5 represents an irregular (osteoporotic)
term seems logical, as this type is fre- fracture that does not fit into any of these 4
quently associated with partial impac- patterns.
3
 | Poster ior Malleolar Fract ures
TABLE I Proposed Treatment for Posterior Malleolar Fractures
According to the Bartonı́ček and Rammelt
Classification29
Type Characteristics
1 Extraincisural
2 Posterolateral
3 2-part with medial extension
4 Large triangular
distal part of the tibia. Hartford et al.54
found that reduction of the distal tibial
articular surface by 25%, 33%, and 50%
resulted in a progressive reduction of the
ankle joint force-bearing area by 4%,
13%, and 22%, respectively. Macko
et al.55 reported a .35% reduction of
the ankle joint contact area with a dis-
placed posterior malleolar fracture
accounting for 50% of the distal tibial
surface. Fitzpatrick et al.56 found no
talar subluxation and no increase in
contact stresses adjacent to an articular
step-off with a posterior malleolar frag-
ment comprising 50% of the articular
surface. However, the authors measured
an anterior and medial shift of the con-
tact stresses following a fracture with a
2-mm step-off, potentially leading to
cartilage overload. Vrahas et al.57 found
no increase in peak stresses with the
removal of posterior malleolar frag-
ments. These studies suggest that with
intact medial and lateral structures,
posterior talar translation results only
with a posterior malleolar fragment size
of .40% of the articular surface. This
corresponds to the findings of Papach-
ristou et al.58 that with the medial and
lateral structures intact or fixed, within
the normal range of motion, the posterior
quarter of the articular surface of the distal
part of the tibia bears almost no load. In
contrast, with the anterior tibiofibular
ligament transected and the fibula os-
teotomized, removal of $30% of the
posterior articular surface resulted in sig-
nificant (p , 0.01) posterior translation
of the talus59.
4 AUGUST 2020
Treatment Options
Nonoperative
Direct fixation from posterolateral
if displaced/impacted
Direct fixation from posterolateral/
posteromedial if displaced/impacted
Direct fixation from posterolateral,
alternatively indirect fixation with
transfibular control of reduction
In a trimalleolar fracture cadaver
model, the ankle-joint contact area
decreased following an oblique poster-
olateral fracture involving ,25% of the
joint surface60. The contact area was
restored to near normal values after
fracture fixation. In experimental PER
stage-4 fractures, direct fixation of the
posterior malleolar fragment restored
stability of the tibiofibular syndes-
mosis significantly better than did a
standard syndesmotic screw61. Both
the posterior tibial rim and the PITFL
absorbed a substantial proportion of
the weight-bearing load of the ankle in
both biomechanical models and
simulations62.
Pathomechanics
The majority of posterior malleolar
fractures occur in the wake of ankle
fractures, with a prevalence of 46% in
Weber Type-B or C fractures3. Ac-
cording to the Lauge-Hansen classifica-
tion, either a ligamentous injury to the
posterior portion of the syndesmosis or
an osseous avulsion of the posterior tibial
rim occurs in SER or pronation-
abduction stage-3 and PER stage-4
fractures63. Smaller fragments (Bar-
tonı́ček and Rammelt Types 1 and 2) are
most likely produced by ligamentous
and capsular avulsions in rotational
injuries28. They are associated with
SER injuries47. Two-part and multi-
fragmentary fractures with intercalary
fragments and large triangular posterior
malleolar fragments (Bartonı́ček and
Rammelt Types 3 and 4, respectively)
are caused by a combination of rota-
tional, abduction, and compression
forces and are correlated with pronation-
abduction and PER fractures47.
The prevalence of posterior malle-
olar fractures in Bosworth fracture-
dislocations is estimated to be 70%50.
The proximal fibular fragment dislocates
behind the posterior tibial tubercle,
leading to the avulsion of smaller frag-
ments50. The fibula frequently becomes
locked between the posterior malleolar
fragment and the distal part of the tibia64.
Isolated posterior malleolar fractures
have a reported prevalence of ,1%65.
These may represent PER or pronation-
abduction stage-2 fractures. Consequently,
a high fibular (Maisonneuve) fracture and
syndesmotic instability have to be ruled out
in these cases66,67. Alternatively, isolated
posterior malleolar fractures may result
from axial compression with the foot in
maximum plantar flexion (“paratrooper
fracture”)68,69. Finally, the posterior mal-
leolus may be fractured in 20% to 25% of
spiral distal tibial shaft fractures48,49,70.
These fractures are typically nondisplaced
and therefore easily overlooked71,72.
Evaluation
The initial radiographic evaluation
should include true anteroposterior,
mortise (20° of internal rotation), and
lateral views of the injured ankle. Pos-
terior malleolar fractures are usually
obvious on the true lateral projection. In
the anteroposterior view, a double con-
tour of the medial malleolus (“flake
fragment” or “spur sign”) indicates a
posterior malleolar fracture with medial
extension42,73. Multiple studies have
shown that the size and 3-dimensional
pathoanatomy of posterior malleolar
fragments cannot be reliably assessed
with radiographs28,29,43,46,74-77. To
obtain relevant information for the
choice of treatment, CT scanning is
warranted with suspected posterior
malleolar fractures24,31,78 (Fig. 3).
Indications for Surgery
Following inferior results of nonoper-
ative treatment of large posterior
· VOLUME 8, ISSUE 8 · e 19.00207
 Poster ior Malleolar Fractures |

Fig. 4
Figs. 4-A and 4-B Indirect reduction of a large posterolateral fragment (Bartonı́ček and Rammelt Type 4) under direct vision. Fig. 4-A Fixation of the posterior
malleolar fragment is achieved with an anterior-to-posterior screw via a small anterior approach while protecting the extensor tendons, the superficial peroneal
nerve, and the anterior tibial neurovascular bundle. The screw threads must be completely within the posterior fragment in order to achieve a lag effect. Fig. 4-B In
oblique Weber Type-B fractures, reduction of the posterior malleolar fracture can be visualized through the fibular fracture, opened with a gently introduced
lamina spreader86.

malleolar fractures39,79, the critical
size for surgical fixation of a posterior
malleolar fragment was, for several
decades, considered to be 25% to 33%
of the articular surface accompanied by
displacement of $2 mm on the
lateral radiograph25,45,79-81. With the
knowledge of the 3-dimensional
pathoanatomy of posterior malleolar
fractures, factors in addition to size and
displacement—namely, the involve-
ment of the incisura, the presence of
intercalary fragments, plafond impac-
tion, and syndesmotic instability—are
increasingly considered in decision-
making 28-31,42,43,52,61,82,83. Conse-
quently, the goals of operative
fixation have been reformulated as
follows 26,28,30,42,61 : (1) restoration
of articular congruity at the posterior
tibial plafond and posterior talar
containment, (2) bone-to-bone res-
toration of the PITFL and, thus,
restoration of syndesmotic stability,
and (3) restoration of the anatomy
and integrity of the fibular notch,
facilitating reduction of the distal
part of the fibula.
On the basis of these considerations
and the 3-dimensional characterization of
the fracture on CT imaging, the following
treatment recommendations (Table I) have
been proposed26,28-30,43,46,61: nonopera-
tive treatment is indicated for Bartonı́ček
and Rammelt Type-1 (extraincisural) and
nondisplaced Type-2 and 3 fractures.
Open reduction and direct internal fixation
is the treatment of choice for Type-2 and 3
fractures with displacement, intercalary
fragments, or partial joint impaction. All
Type-4 (large triangular) fractures are
generally treated by open reduction and

Fig. 5-A
Anteroposterior and lateral radiographs of a
trimalleolar fracture.

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 | Poster ior Malleolar Fract ures

Fig. 5-B
Axial and sagittal CT imaging reveals a
displaced posterolateral posterior malleolar
fracture (Bartonı́ček and Rammelt Type 2) with
an impacted intercalary fragment (straight
arrow). Note how the fragment follows the
anteriorly displaced fibula through the pull of
the PITFL (curved arrow).

direct or indirect internal fixation in order
to restore overall ankle stability. Even if
nondisplaced, primary (“joint first”) fixa-
tion should be performed in the presence of
distal tibial spiral fractures to avoid sec-
ondary displacement during intramedul-
lary nailing48,49,71,72.
Typically, nondisplaced isolated
posterior malleolar fractures are treated
nonoperatively, provided syndesmotic
instability has been ruled out67-69,84,85.
In addition to considering the pathoa-
natomy of the posterior malleolar frac-
ture, the individual choice of treatment
depends on the overall pattern of injury to
the ankle, i.e., the morphology of the
fibular fracture and injury to the anterior
and medial structures, as well as the
overall condition of the patient30,86-88.
Surgical Approaches and
Fixation Techniques
Primary reduction and fixation of posterior
malleolar fragments involving the incisura
recreates the fibular notch and facilitates
fibular reduction30,40,43,86-88. If the fibula
is reduced into a deformed and unstable
incisura, posterior and rotational mala-
lignment of the fibula may occur, further
preventing reduction of the posterior mal-
leolar fragment30,40. Furthermore, with a
fibular plate or other hardware in place, it
may be impossible to adequately assess the
quality of reduction of the tibial joint
surface86,87. Anatomic restoration of the
posterior malleolus also helps in reducing

Fig. 5-C
Left panel Direct reduction via a posterolateral approach starts with the intercalary fragment that is reduced congruently to the joint surface and fixed
provisionally with a Kirschner wire. The latter can be left in place and cut flush with the intercalary fragment and buried. In the present case, the
fragment was definitively fixed with a resorbable pin. Middle panel The posterolateral fragment that was left hinged on the PITFL is then reduced to
the joint surface and fixed with a posterior plate. Right panel The fibular fracture is reduced and fixed with a posterior antiglide plate through the same
approach, and the medial malleolus is fixed with 2 screws via a medial approach (with the patient prone). The syndesmosis was found to be stable on
intraoperative hook testing after internal fixation of the medial and lateral malleoli and the posterior malleolar fracture.

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 Poster ior Malleolar Fractures |

Fig. 5-D
Standing radiographs at 8 weeks postopera-
tively show solid bone-healing and a well-
aligned ankle joint.

the distal part of the fibula to its proper
length through the pull of the PITFL26.
Indirect Reduction and Anterior-to-
Posterior Screw Fixation
Indirect reduction with anterior-to-
posterior screw fixation has been popu-
lar for several decades45,80,81,87,88. It is
most suitable for large fragments (Bar-
tonı́ček and Rammelt Type 4) without
intercalary fragments or impaction. The
patient is placed supine or in the lateral
decubitus position. The posterior frag-
ment is mobilized by dorsiflexion of the
ankle and manipulation with a sharp
elevator. Fine reduction is achieved with
a pointed reduction clamp introduced
between the anterior and posterior tibial
tubercles (Fig. 4). The quality of reduc-
tion is checked with a lateral radiograph
and ideally under direct vision through
the fibular fracture site (the transfibular
reduction method described by
Weber86,88). Fragment fixation is
achieved using partially threaded com-
pression screws introduced tangential to
the joint surface through an anterior
incision81,86,88.
Direct Reduction and Fixation from a
Posterolateral Approach
The majority of posterior malleolar frac-
tures can be reduced and fixed directly via a

Fig. 6-A
Left panel Anteroposterior and lateral radiographs of a supination-external rotation stage-3 ankle fracture in a 28-year-old female patient with a body mass index of 29 kg/m2.
Note the pathognomonic double contour at the medial malleolus. Axial (middle panel) and sagittal (right panel) CT images reveal a Bartonı́ček and Rammelt Type-3 fracture
(equivalent to Haraguchi Type-II) with extension into the medial malleolus and a depressed intercalary fragment (arrows in the middle and right panels ). Direct reduction and fixation of
both the posterior and lateral malleoli is achieved via a posterolateral approach. The intercalary fragment is reduced flush to the joint surface and fixed with a resorbable pin.

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 | Poster ior Malleolar Fract ures

Fig. 6-B
The ankle mortise is congruent and the
syndesmosis is stable on dynamic testing with
external rotation after fixation of the posterior
malleolus and the distal part of the fibula via
the same posterolateral approach.

posterolateral approach26,30,52,83,86,88.
This approach is particularly useful with
relatively small posterior malleolar frag-
ments and in the presence of intercalary
fragments or impacted plafond fragments
(Figs. 5-A through 5-D) that are not
amenable to indirect reduction as regularly
seen in Bartonı́ček and Rammelt Type-2
and 3 fractures29,30,46,86. A concomitant
distal fibular fracture can be reduced and
stabilized with a posterior antiglide plate
via the same incision86,87.
The patient is placed in the prone
position. A longitudinal incision is
made halfway between the distal part of
the fibula and the Achilles tendon. The
sural nerve is protected in the subcu-
taneous tissue. The superficial and deep
fascia are dissected. An interval is cre-
ated bluntly between the flexor hallucis
longus and the peroneal muscles. Care
must be taken not to injure the peroneal
artery that perforates the interosseous
membrane 6 cm proximal to the ankle
joint89. The posterolateral fragment is
gently mobilized and hinged on the
PITFL. The metaphyseal fracture line
is used as a reference for reduction.
Intercalary and impacted joint frag-
ments of sufficient size and cartilage
quality are reduced toward the tibial
plafond using the talus as a template
and fixed with buried Kirschner wires
or resorbable pins86. Comminuted
fragments not amenable to fixation are
resected.
Options for internal fixation
include the use of lag screws with
washers, cortical screws inserted in a
lag technique, or a posterior buttress
plate (Figs. 6-A, 6-B, and 6-C). Sev-
eral biomechanical studies have
demonstrated stronger fixation with
the use of posterior plates compared
with both anterior-to-posterior
screws 90,91 and posterior-to-anterior
screws 92 . For Haraguchi Type-I
fractures, Wang et al. 93 did not find
superior fixation strength of a poste-
rior plate compared with posterior-
to-anterior screws using a simulated

Fig. 6-C
Axial (left panel) and sagittal (center and right panels) postoperative CT scans reveal anatomic reduction of the tibial incisura and joint congruity
including the intercalary fragment (arrow in right panel).

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TABLE II Results of Treatment of Posterior Malleolar (PM) Fractures from the Literature After 2000*
Study
123
Langenhuijsen et al. (2002)
Weber42 (2004)
De Vries et al.90 (2005)
Bois and Dust96 (2008)
Forberger et al.131 (2009)
82
Miller et al. (2010)
Heim et al.25 (2010)
Abdelgawad et al.134 (2011)
Wang et al.135 (2011)
Mingo-Robinet et al.121 (2011)
Huang et al.136 (2012)
Xu et al.122 (2012)
Klammer et al.52 (2013)
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Poster ior Malleolar Fractures |
Fracture Characteristics,
No. of Cases Average Follow-up (yr) Intervention Main Results
57 6.9 Fragment size 8%-55%, fixation No difference in outcomes with
in 25%, residual step-off in 32% respect to PM fragment size and
fixation, step-off in fragments
$10% of the articular surface
with significantly poorer
prognosis
10 1.4 Combined posteromedial and AOFAS, 94
posterolateral approach for 1 patient with malunited fracture
fragments involving the entire developed posteromedial
posterior plafond instability
45 13 Internal fixation (n 5 11) vs. No difference in pain, function,
nonoperative treatment (n 5 34) and arthritis with respect to PM
fragment size and fixation
12 9.4 Direct fixation via posteromedial Global foot and ankle score, 87
approach Arthritis grade 0-I (n 5 4), grade II-
III (n 5 8)
45 2.1 Direct fixation via posterolateral AAOS, 93
approach, median fragment size Only marginal loss of range of
24% motion
11% soft-tissue problems
1 (2%) revision
17 1.3 Direct fixation via posterolateral FAOS, 56-87 (depending on
approach regardless of size domain)
Anatomic reduction of
syndesmosis through PM fixation
11 7.3 Direct fixation via posterolateral OM, 91
approach for PM fragment size Cartilage damage at time of
.25% injury leads to more severe
arthritis
12 1 Direct fixation via posterolateral 2 cases of $2-mm articular
approach for PM fragment size surface displacement
.30%
12 1.5 Combined posteromedial and No postoperative step-off
posterolateral approach for AAOS, 86
fragments involving the entire
Osteoarthritis score, 0.8
posterior plafond
45 2 Fixation in 40%, residual step-off Significantly inferior results with
in 27% fragment size .25%
32 2.2 Direct fixation via posterolateral 100% union rate
approach
102 2.8 Patients from multiple centers, No relation between fragment
fixation in 41% (mean size, 28%), size and outcome
nonoperative in 59% (mean size, Step-off .1 mm with worse
12%), residual step-off .1 mm in functional and radiographic
24% results (p 5 0.01 for AOFAS; p 5
0.000 for osteoarthritis scale)
11 1.9 Posterior pilon variant (partial AOFAS, 82
joint impaction), direct fixation 5 patients with complications
via posterolateral approach warranting reintervention
2 patients with complex regional
pain syndrome
continued
9
 | Poster ior Malleolar Fract ures
TABLE II (continued )
Study
Erdem et al.137 (2014)
Ruokun et al.138 (2014)
Choi et al.110 (2015)
Kim et al.111 (2015)
O’Connor et al.128 (2015)
Drijfhout van Hooff et al.112 (2015)
Evers et al.124 (2015)
Karaca et al.139 (2016)
Verhage et al.83 (2016)
Wang et al.140 (2016)
Vidović et al.19 (2017)
Bali et al.141 (2017)
Shi et al.109 (2017)
Zhong et al.98 (2017)
10
Fracture Characteristics,
No. of Cases Average Follow-up (yr) Intervention Main Results
40 3.2 Direct fixation with posterior No difference in outcome after
screws or plate (50% each), direct posterior screw (AOFAS,
residual step-off in 5% 94) vs. plate (AOFAS, 95) fixation
32 3.2 Direct fixation via posterolateral AOFAS, 92
approach, mean fragment size
19%, postoperative step-off in
9%
50 2.2 Single oblique posterolateral AOFAS, 91
approach for Haraguchi Type-I OM, 90
fractures, residual step-off in 4%
36 3.3 Lateral transmalleolar approach SMFA dysfunction index, 8.2
of large fragments (mean size SMFA bother index, 832
44%)
27 3.7 Buttress plating via Significantly better SMFA bother
posterolateral approach (n 5 16) index (p 5 0.03), trend toward
vs. indirect fixation and better function and mobility (p 5
percutaneous AP screw (n 5 11) 0.08) after direct buttress vs. AP
screw fixation
131 6.9 Fixation in 18% (fragment size Significantly inferior
.25%), residual step-off in 42% radiographic results, higher rate
of arthritis with step-off .1 mm
(p 5 0.02) for those with frag-
ment size .5%
No difference in functional
outcomes with respect to PM
fragment size
42 2.5 Fixation in 35% No difference in outcomes with
respect to PM fragment size
57 3.9 Direct fixation via posterolateral AAOS, 92
approach, mean fragment size
21%
52 0.7 Direct fixation with posterior lag Reduction within 1 mm
screw (23%) or buttress plate 0% postoperative step-off with
(77%) direct fixation, 8% osteoarthritis,
26% hardware removal
16 2.3 Direct fixation of posterior pilon AOFAS, 86
variant fractures from
posteromedial
46 1.7 Indirect AP vs. direct fixation via Significantly better quality of
posterolateral approach (50% reduction (p 5 0.04) and trend
each); fragment size .25% toward better range of motion (p
5 0.07) after direct fixation
15 2.4 Posteromedial approach for OM, 72
Haraguchi Type-II fractures,
postoperative step-off in 33%
116 1.7 Indirect AP (n 5 52) vs. direct Significantly less step-off (p 5
fixation via posterolateral 0.038) and better AOFAS scores
approach (n 5 64) (p 5 0.034) after direct fixation
48 1.8 Posteromedial (n 5 20) vs. No difference in quality of
posterolateral (n 5 28) approach reduction and outcomes for
for direct fixation, mean posteromedial (AOFAS, 93) vs.
fragment size 22%, posterolateral (AOFAS, 92)
postoperative step-off in 8% approach
continued
AUGUST 2020 · VOLUME 8, ISSUE 8 · e 19.00207

TABLE II (continued )
Study
Kalem et al.142 (2018)
Levack et al.125 (2018)
Blom et al.132 (2019)
Mason et al.143 (2019)
Verhage et al.130 (2019)
Kang et al.127 (2019)
Meijer et al.144 (2019)
McHale et al.145 (2020)
Tuček et al.146 (2020)
*Percentages of posterior malleolar fragment size refer to the total joint surface on lateral radiographs. AOFAS 5 American Orthopaedic Foot & Ankle
Society Ankle-Hindfoot Scale, AAOS 5 American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire, FAOS 5 Foot and Ankle Outcome
Score, OM 5 Olerud-Molander Ankle Score, SMFA 5 Short Musculoskeletal Function Assessment, AP 5 anterior-to-posterior (indirect) screw fixation,
and MOXFQ 5 Manchester-Oxford Foot and Ankle Questionnaire.
AUGUST 2020 · VOLUME 8, ISSUE 8 · e19.00207
Poster ior Malleolar Fractures
Fracture Characteristics,
No. of Cases Average Follow-up (yr) Intervention
67 2.2 AP screws vs. direct posterior
screw or plate fixation
122 1.4 Fragment size 2%-50%, direct
posterolateral plate fixation for
PM fractures, and ligament repair
for bimalleolar fractures with
PITFL rupture
73 2 Direct fixation of 40% of
Haraguchi Type-I, 62% of Type-II,
and 3% of Type-III fractures
50 1 Direct posterolateral or
posteromedial fixation of PM
fractures involving the incisura
169 6.3 Average fragment size 17%
62 1 Screw fixation (n 5 32) vs. no
fixation (n 5 30) of PM fragment
(,25%) in trimalleolar fractures
31 1 18 patients (58%) with direct
fixation of the PM fragment
31 Min. 1.2 Retrospective study of
operatively fixed PM fractures
based on questionnaires
19 2.9 Direct posterior fixation of
Bartonı́ček and Rammelt Type- 4
fractures with an antiglide plate
|
Main Results
Better radiographic reduction
and AOFAS scores (p , 0.001)
with direct posterior fixation
FAOS, 53-82 (depending
on domain); similar results
after trimalleolar fractures
with PM fracture and
bimalleolar fractures with
PITFL rupture with injury-
specific treatment
Significantly poorer outcome
for Haraguchi Type-II fractures
compared with Type-III (all
FAOS domain scores) and
Type-I (FAOS domain scores
for symptoms and activities of
daily living)
OM, 74
Visual analogue scale for health, 75
AAOS, 92
AOFAS, 93
Step-off .1 mm (in 39%)
independent risk factor for
arthritis (seen in 30%), associated
with worse outcome
Patients without PM fixation
had a step-off ($2 mm) in
2 of 30 cases and inferior
outcome (AAOS, AOFAS) at 6
and 12 mo
Step-off as seen on postoperative
CT (0-2.7 mm) but not gap showed
significant correlation with FAOS
(p 5 0.05); fragment size correlated
with arthrosis (p 5 0.01)
MOXFQ, 26.9
Worst clinical outcomes for
smaller PM fragments (10%-
20%) mostly treated without
direct fixation, while larger
fragments were more likely to be
fixed posteriorly and were
associated with a more
anatomic reduction
Better scores (AOFAS, 93.1) with
anatomic reduction than with
satisfactory reduction (AOFAS,
89.1) as controlled with
postoperative CT
11
 | Poster ior Malleolar Fract ures

TABLE III Recommendations for Care*

Recommendation Recommendation Grade

CT scanning is essential for detecting the exact 3-dimensional fracture anatomy, B

classification, and treatment planning in posterior malleolar fractures
Operative treatment should be considered for posterior malleolar fragments B
with displacement ($2 mm), involvement of the fibular notch of the distal part of
the tibia (incisura), the presence of an intra-articular step-off ($2 mm), or a
depressed intercalary fragment
Fixation of a displaced posterior malleolar fragment restores the integrity of the B
posterior inferior tibiofibular syndesmosis and significantly reduces the need for
additional syndesmotic stabilization
Anatomic reduction of posterior malleolar fragments restores the tibial incisura B
and thus facilitates reduction of the distal part of the fibula
Direct open reduction and fixation of posterior malleolar fragments via B
posterolateral and posteromedial approaches is biomechanically more stable
and provides a more accurate reduction than indirect reduction and anterior-to-
posterior screw fixation
Screw fixation of the posterior malleolus should precede intramedullary nailing B
in concomitant posterior malleolar and distal tibial shaft fractures
Relevant malalignment should be corrected as early as possible upon detection C
in order to avoid joint incongruity, chronic syndesmotic instability, and
posttraumatic ankle arthritis

*According to Wright147, grade A indicates good evidence (Level-I studies with consistent findings) for or against recom-
mending intervention; grade B, fair evidence (Level-II or III studies with consistent findings) for or against recommending
intervention; grade C, poor-quality evidence (Level-IV or V studies with consistent findings) for or against recommending
intervention; and grade I, insufficient or conflicting evidence not allowing a recommendation for or against intervention.

gait cycle model, but the authors
conceded that their study might have
been underpowered. In a finite
element model analysis, a posterior
buttress plate produced greater
stability and less displacement com-
pared with either posterior-to-anterior or
anterior-to-posterior screws94. In osteo-
porotic bone, locking-plate fixation is
generally preferred95.
Direct Reduction and Fixation from a
Posteromedial Approach
A posteromedial approach enables access
to the posterior tibial rim and the medial
malleolus42,52,96-99. It is especially use-
ful in certain Bartonı́ček and Rammelt
Type-3 (Haraguchi Type-II) fractures
with medial displacement. Zhong
et al.98, however, had similar clinical and
radiographic outcomes with posterome-
dial and posterolateral approaches. The
patient is placed in the prone position. The
incision runs longitudinally halfway
between the Achilles tendon and the
medial malleolus. After entering the fascia,
the posteromedial neurovascular bundle is
identified and gently retracted medially
along with the flexor digitorum longus and
posterior tibial tendons, while the flexor
hallucis longus tendon is retracted later-
ally97. Reduction and fixation of the
posterior tibial fragment is performed
analogously to the posterolateral approach.
Necessity of Syndesmotic Fixation
The fixation of posterior malleolar frac-
tures aims to achieve bone-to-bone resto-
ration of syndesmotic stability26,30,61,100.
In a study on 236 patients, Baumbach
et al.101 found that posterior malleolar
fixation significantly (p , 0.001) reduced
the need for syndesmotic fixation inde-
pendently of fragment size. Direct fixation
of posterior malleolar fragments resulted
in a significantly better reduction than
either closed reduction and indirect fixa-
tionornonoperativetreatment(p,0.001).
Similarly, Miller et al.102 and Li et al.103, in
studies with 198 and 97 patients, respec-
tively, found that posterior malleolar fixa-
tion significantly (p , 0.001) reduced the
frequency of syndesmotic fixation. In
another study with only 27 patients, the
authors did not find a significantly reduced
need for additional syndesmotic fixation
afterposteriormalleolar fixation104.Verhage
et al.83 found that 9 of 11 patients with
Weber Type-C fractures had a stable syn-
desmosis after fixation of the posterior mal-
leolar fragment. Therefore, from the
available literature, posterior malleolar fixa-
tion seems to obviate the need for additional
syndesmotic fixation in a substantial num-
ber of cases. This is of particular interest
becausethe presenceof asyndesmotic injury
requiring fixation is strongly associated with
inferior outcomes104.
Posterior Malleolar Fractures
Associated with Distal
Tibial Fractures
Concomitant posterior malleolar frac-
tures are reported in about 9% of cases of
tibial shaft fracture105,106. Using CT,
Hendrickx et al.49 found an associated
posterior malleolar fracture in 22% of
164 tibial shaft fractures and in 56% of

12 AUGUST 2020 · VOLUME 8, ISSUE 8 · e 19.00207


simple spiral fractures of the tibia, with
25% being occult on radiographs.
Multivariate analysis revealed distal-
third and simple spiral tibial shaft frac-
tures as independent predictors of a
posterior malleolar fracture. Kellam
et al.107 found posterior malleolar frac-
tures to be significantly larger when
associated with tibial shaft fractures
compared with ankle fractures (32%
versus 15% of cross-sectional area;
p , 0.001). When evaluating 50 three-
dimensional models, Zhang et al.48
found a significant risk of fragment dis-
placement by intramedullary nail inser-
tion if the fracture extended .31 mm
proximal to the plafond. Kempegowda
et al.106 found intraoperative posterior
malleolar displacement in 31% and a
poor reduction in 44% of 16 patients
treated with intramedullary nailing first.
In contrast, a rate of only 2% displace-
ment and poor reduction was observed
among 54 patients treated with fixation of
the posterior malleolus first (p , 0.01).
Screw fixation of the posterior malleolus
should therefore precede intramedullary
nailing in these injuries.
Complications
With a posterolateral approach, superfi-
cial wound infection was reported in 5%
and deep infection requiring revision
surgery in 1% of cases in 1 systematic
review108, with similar rates reported in
several other studies19,83,98,109. The
authors of 1 study reported temporary
numbness at the lateral part of both
the heel and forefoot, suggesting neura-
praxia of the sural nerve, in 4% of cases83.
Similarly, a single oblique lateral
approach for posterior screw fixation
of the posterior malleolus and lat-
eral plating of the distal part of the
fibula was associated with superficial
wound infection and sural nerve in-
jury in 0% to 4% of cases in 2 other
studies110,111.
Malalignment of posterior malle-
olar fragments, as defined as a step-off of
$2 mm in the articular surface, has been
reported after operative treatment in up
to 42% of cases, mostly following indi-
rect reduction and percutaneous screw
AUGUST 2020 · VOLUME 8, ISSUE 8 · e19.00207
fixation112. Several studies demon-
strated a significantly higher quality of
reduction (p , 0.001 to p 5 0.04 for
postoperative step-off) with direct pos-
terior malleolar fixation via posterior
approaches compared with indirect
reduction and percutaneous anterior-to-
posterior screw fixation19,101,109,113.
Open reduction and direct posterior-
to-anterior screw fixation of PITFL
avulsions has been shown to reduce the
rate of malreduction of the distal part
of the fibula into the incisura by a
factor of 4.5 compared with closed
reduction and syndesmotic screw
fixation114.
Only a few authors have reported
on successful joint-sparing corrective
osteotomies of malunited posterior
malleolar fragments in the absence of
symptomatic arthritis115-117. Posttrau-
matic osteoarthritis is seen clinically or
radiographically in about one-third of
patients with a posterior malleolar
fracture118. Ankle arthrodesis or an-
kle replacement with realignment
remains a salvage option in sympto-
matic patients.
Outcomes and Prognosis
A multitude of studies have shown that,
in malleolar fractures, the mere presence
of a posterior tibial fragment is associ-
ated with less favorable outcomes
and higher rates of posttraumatic
arthritis1,9-13,25,82,90,118-123. The size of
the posterior malleolar fragment has
been correlated with both functional
results and the degree of osteoarthritis in
several studies1,10,25,119-122, while a
correlation between fragment size and
outcome was not found in other
studies90,111,123,124. A systematic review
suggested that it is not the size of the
posterior fragment but rather displace-
ment and articular incongruity includ-
ing tibiotalar subluxation that are
prognostically important118. As with
any fracture associated with syndesmotic
instability, the outcome is determined
by the quality of distal fibular reduction
into the incisura10,11,82,100,118,125.
The results of some comparative
studies are inconsistent. While some did
Poster ior Malleolar Fractures |
not reveal significant differences in
results when comparing nonoperative
and operative treatments of posterior
malleolar fractures with fragments
involving up to 25% of the articular
surface40,90,126, others found that, for
larger posterior malleolar fragments, the
results of open reduction and internal
fixation were better than those of non-
operative treatment1,39,119,127. O’Con-
nor et al.128 found superior clinical
outcomes after posterior buttress plating
versus anterior-to-posterior screw fixa-
tion for posterior malleolar fracture
fixation.
Several clinical studies identi-
fied a postoperative step-off of
$2 mm as an independent risk factor
for inferior outcomes and the devel-
opment of posttraumatic ankle
osteoarthritis 112,122,123,127,129,130 .
Step-off was independent of the
fragment size, and poorer results were
observed even with small posterior
malleolar fragments comprising as
little as 5% or 10% of the articular
surface 112,123 .
Various studies reported favorable
results at 1 to 9 years after posterior
malleolar fixation via a posterolateral or
posteromedial
approach42,52,98,110,131-146 (Table II).
In a clinical study of 73 patients, Blom
et al.132 found that Haraguchi Type-II
(Bartonı́ček and Rammelt Type-3)
posterior malleolar fractures showed
significantly poorer Foot and Ankle
Outcome Score values for symptoms
(p 5 0.03), pain (p , 0.01), and activ-
ities of daily living (p , 0.01) at 2 years
of follow-up compared with other types.
In the few available studies on isolated
posterior malleolar fractures, the long-
term results of nonoperative treatment
are good to excellent68,69,85,133. Despite
the large number of clinical studies, the
evidence is limited because of their
mostly retrospective design, their
assessment of fracture anatomy and
reduction using radiographs only, and
the lack of uniform treatment. Recom-
mendations for treatment based on the
current literature are summarized in
Table III.
13
 | Poster ior Malleolar Fract ures
Stefan Rammelt, MD, PhD1,
Jan Bartonı́ček, MD, PhD2,3
1University
Center of Orthopaedics and
Traumatology, University Hospital Carl
Gustav Carus Dresden, Dresden, Germany
2Department of Orthopaedics, First
Faculty of Medicine, Charles University
and Central Military Hospital Prague,
Prague, Czech Republic
3Department
of Anatomy, First Faculty of
Medicine, Charles University Prague,
Prague, Czech Republic
Email address for S. Rammelt:
strammelt@hotmail.com
Email address for J. Bartonı́ček:
bartonicek.jan@seznam.cz
ORCID iD for S. Rammelt:
0000-0003-1141-6493
ORCID iD for J. Bartonı́ček:
0000-0002-2228-1443
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