Effectiveness of Diagnosis and Treatment of Spiral Fracture of the Distal Third of the Tibia Combined with Posterior Malleolus Fracture

Chen, Qun; Song, Lijun; Fang, Jiahu; Qin, Xiaodong; Lv, Tianrun; Li, Xiang

doi:10.7547/15-181

Cited by 10 publications

(8 citation statements)

References 25 publications

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“…In the present review, we have confirmed that the highest incidence of PMFs in this combined injury was mainly focused on spiral TSFs, especially distal third spiral TSFs, which may be due to the injury mechanism and special anatomical structure [ 5 , 31 – 33 ]. Based on a CT scan or MRI, the mean incidence of PMFs in patients with spiral TSFs and distal third spiral TSFs was 70% (56–88.2%) and 70.4% (35.7–92.3%), respectively.…”

Section: Discussionsupporting

confidence: 53%

“…Seventeen studies reported surgical intervention strategies for PMFs. Among them, 6 studies indicated that surgical fixation should be performed when PMF is recognized [ 1 , 2 , 4 , 5 , 11 , 13 ]; 6 studies suggested that surgical fixation should be performed when PMF is displaced, involving over 25% of the articular surface, instability, or a large fragment [ 6 , 14 , 19 – 21 , 25 ]; and the remaining 5 studies only reported the percentage of surgical fixation. In patients with the combined injury who met the inclusion criteria, the treatment strategies for PMFs were inconsistent.…”

Section: Resultsmentioning

confidence: 99%

“…Generally, intramedullary nails and hollow screws or cortical lag screws are direct and effective methods to treat TSFs and PMFs [ 11 , 37 – 39 ]. However, whether PMFs need to be fixed and the sequence of fixation—whether the TSFs or PMFs should be fixed first—have inadequate data [ 5 , 22 , 40 ]. A survey of American surgeons showed that there is no definite consensus on the range and standards of PMF treatment [ 33 , 41 ].…”

Section: Discussionmentioning

confidence: 99%

“…However, current literature shows that the PMFs associated with TSFs are often overlooked because PMFs are mostly occult and non-displaced [ 9 , 14 ]. Most of the fracture lines are coronal, which are usually difficult to detect on anteroposterior or lateral plain radiographs [ 5 , 6 ]. The need for fixation of the PMFs is still subject to debate.…”

Section: Introductionmentioning

confidence: 99%

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Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review

et al. 2021

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Background Tibial shaft fractures (TSFs) combined with occult posterior malleolar fractures (PMFs) are becoming widely recognized in the field of orthopedics. The purpose of this study was to determine the clinical incidence, missed diagnosis rate, and treatment strategies of this combined injury. Methods PubMed, Cochrane, and MEDLINE Ovid databases were searched for articles of English language from 1988 to 2020, identifying 1549 papers. Results Twenty-one of the 1278 identified studies were eligible for inclusion. Each study reported on the incidence of this combined injury, and 12 studies documented the missed diagnosis rate. Seventeen studies reported surgical intervention strategies for PMFs. In the present review, PMFs frequently occurred in spiral TSFs (70%), especially distal third spiral TSFs (70.4%), based on CT scans or additional MRI. Based on the original X-ray detection, approximately 50% of PMFs were missed in patients with a combined injury. In addition, the treatment strategies for PMFs were inconsistent. Most studies (11/17) believe that specific surgical management needs to be developed based on the fragment size, displacement, and stability of the PMF. Conclusions For patients with TSFs, spiral TSFs, especially distal third spiral TSFs, are closely related to PMFs and are often not sufficiently diagnosed by X-ray alone. Advanced CT and MRI examinations can significantly reduce the missed diagnosis rate of occult PMFs. According to available literature, the treatment strategy for PMFs associated with TSFs is questionable without convincing evidence of benefit.

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Section: Discussionsupporting

confidence: 53%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review

et al. 2021

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“…In addition, the same study showed that the size of the posterior tibial edge fragment is mostly underestimated in plain X-rays [1]. Two other recently published studies by Chen et al and Mitchell et al showed similar results for spiral fractures in the distal third of the tibia [6,13]. Spiral tibial shaft fractures, particularly in the middle third of the tibia, were not investigated in these studies.…”

Section: Discussionmentioning

confidence: 83%

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study

Lisitano

Mayr

Rau

et al. 2022

Eur J Trauma Emerg Surg

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Introduction An undislocated fracture of the posterior malleolus is a common concomitant injury in tibial shaft spiral fractures. Nevertheless, these accompanying injuries cannot always be reliably assessed using conventional X-rays. Thus, the aim of the study is to evaluate how often a fracture of the posterior malleolus occurs with tibial shaft fractures (AO:42A/B/C and AO:43A) and which factors—identifiable in conventional X-rays—are predictive. Methods Retrospective evaluation of X-ray and CT images revealed a total of 103 patients with low-energy tibial shaft fractures without direct joint involvement. Proximal fractures and fractures involving the knee were excluded. Basic data on injury, the trauma mechanism, the path of the fracture, bony avulsions of the posterior syndesmosis and the procedures performed were evaluated. Results Thirty-nine fractures were located in the middle third of the tibia, 64 in the distal third. In 65 cases, a spiral fracture (simple or wedge fracture) was found. In 31/103 fractures, an additional osseous avulsion of the posterior syndesmosis could be detected, 5 (16.1%) of them were not recognized preoperatively due to an absence of CT imaging. In three of these patients, a fracture of the posterior malleolus was only recognized postoperatively, and an additional surgery was necessary. The spiral fractures were classified in the a.p. X-ray according to their path from lateral proximal to medial distal (Type A) or from medial proximal to lateral distal (Type B). A Pearson chi-square test and Fisher’s exact test showed a highly significant accumulation of accompanying posterior malleolus fractures for type A fractures (p = 0.001), regardless of the location of the fracture. In addition, the fractures with involvement of the posterior malleolus had a significantly higher proportion in the fractures of the distal third (p = 0.003). There was no statistically significant relationship between the height of the fracture and the path of the fracture (type A or B). These two factors seem to be independent factors for participation of the posterior malleolus. Conclusion In 40.6% of the tibial shaft fractures in the distal third, in 56.9% of the type A spiral fractures and in 67.6% of the type A fractures in the distal third, the ankle joint is involved with bony avulsion of the posterior syndesmosis, which is not always recognized in conventional X-rays. To avoid complications such as additional operations, instability and post-traumatic arthrosis, we recommend preoperative imaging of the ankle using CT for these fractures. Level of evidence III, retrospective cohort study. Trail registration number DRKS00024536.

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Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial

Lisitano,

Röttinger,

Wiedl

et al. 2023

Eur J Trauma Emerg Surg

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Purpose Tibial shaft spiral fractures and fractures of the distal third of the tibia (AO:42A/B/C and 43A) frequently occur with non-displaced posterior malleolus fractures (PM). This study investigated the hypothesis that plain X-ray is not sufficient for a reliable diagnosis of associated non-displaced PM fractures in tibial shaft spiral fractures. Methods 50 X-rays showing 42A/B/C and 43A fractures were evaluated by two groups of physicians, each group was comprised of a resident and a fellowship-trained traumatologist or radiologist. Each group was tasked to make a diagnosis and/or suggest if further imaging was needed. One group was primed with the incidence of PM fractures and asked to explicitly assess the PM. Results Overall, 9.13/25 (SD ± 5.77) PM fractures were diagnosed on X-ray. If the posterior malleolus fracture was named or a CT was requested, the fracture was considered “detected”. With this in mind, 14.8 ± 5.95 posterior malleolus fractures were detected. Significantly more fractures were diagnosed/detected (14 vs. 4.25/25; p < 0.001/14.8 vs. 10.5/25; p < 0.001) in the group with awareness. However, there were significantly more false positives in the awareness group (2.5 vs. 0.5; p = 0.024). Senior physicians recognized slightly more fractures than residents (residents: 13.0 ± 7.79; senior physicians: 16.5 ± 3.70; p = 0.040). No significant differences were demonstrated between radiologists and trauma surgeons. The inner-rater reliability was high with 91.2% agreement. Inter-rater reliability showed fair agreement (Fleiss-Kappa 0.274, p < 0.001) across all examiners and moderate agreement (Fleiss-Kappa 0.561, p < 0.001) in group 2. Conclusion Only 17% of PM fractures were identified on plain X-ray and awareness of PM only improved diagnosis by 39%. While experiencing improved accuracy, CT imaging should be included in a comprehensive examination of tibial shaft spiral fractures. Level of evidence II. Diagnostic prospective cohort study. Trail registration number DRKS00030075.

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Effectiveness of Diagnosis and Treatment of Spiral Fracture of the Distal Third of the Tibia Combined with Posterior Malleolus Fracture

Abstract: Computed tomography helped identify most posterior malleolus fractures, and radiography alone might miss it. Intramedullary nailing and posterior malleolus screw fixation were straightforward and effective treatments.

Cited by 10 publications

References 25 publications

Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review

Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review

Accompanying injuries in tibial shaft fractures: how often is there an additional violation of the posterior malleolus and which factors are predictive? A retrospective cohort study

Plain X-ray is insufficient for correct diagnosis of tibial shaft spiral fractures: a prospective trial

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