The outcome at 20 years of conservatively treated ‘isolated’ posterior malleolar fractures of the ankle

Abstract

We assessed the long-term (20 years) outcome of closed reduction and immobilisation in 19 patients with an isolated fracture of the posterior malleolus of the ankle treated at a single hospital between 1985 and 1990. The assessments used were an Olerud functional questionnaire score, physical examination using a loaded dorsal and plantar range of movement measurement, radiological analysis of medial joint space widening, the Cedell score for anatomical alignment of all three malleoli, and the radiological presence of osteoarthritic change. There were excellent or good results in 14 patients (74%) according to the Olerud score, in 18 patients (95%) according to loaded dorsal and plantar range of movement assessment, in 16 patients (84%) as judged by the Cedell score, and for osteoarthritis 18 patients (95%) had an excellent or good score. There were no poor outcomes. There was no correlation between the size of the fracture gap and the proportion of the tibiotalar contact area when compared with the clinical results (gap size: rho values -0.16 to 0.04, p ≥ 0.51; tibiotalar contact area: rho values -0.20 to -0.03, p ≥ 0.4). Conservative treatment of 'isolated' posterior malleolar fractures resulted in good clinical and radiological outcome in this series at long-term follow-up.

Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature

“…1). A total of 19 studies met our inclusion criteria and were included for data analysis (Table 1) [1,6,7,11,12,[19][20][21][22][23][24][25][26][27][28][29][30][31][32]. There were five level II studies [1,19,20,26,29], 11 level III studies [6,7,12,[21][22][23]25,27,28,31,32], and three level IV studies [11,24,30].…”

“…Posterior malleolar fractures are often caused by pronation or supination external rotation trauma, also causing fracture of the lateral and medial malleolus, as described by the Lauge-Hansen classification [4]. Isolated posterior malleolar fractures are rare [5][6][7]. In current literature there is an ongoing debate on whether or not to apply osteosynthesis (internal fixation) on a posterior malleolar fragment and at which cut-off point to do this, considering its size and the amount of displacement [8].…”

“…Also, displacement of the posterior malleolar fragment of >2 mm is an indication for surgical fixation of the fragment [8,11]. Posttraumatic osteoarthritis is a common consequence of posterior malleolar fractures [1,6,8,12]. This is a result of damage to the cartilage due to the trauma, malreduction of the fracture fragment and ankle instability [13,14].…”

Fracture of the posterior malleolus: an underdiagnosed condition

“…4,17,18 It has been reported that posterior malleolus fractures involving small fragments (up to 25% of the articular surface) present good outcomes when treated conservatively, without the need for fixation surgical procedures. [19][20][21] Nonetheless, fragments bigger than 25-30% of the articular surface and with articular incongruence (anteroposterior difference greater than 2 mm), the internal fixation of the fragment is indicated. 6,22,23 In this sense, a posterolateral approach provides a more direct access due to space created between the fibular and Achilles tendons.…”

Fracture isolée de la marge postérieure du tibia : un diagnostic oublié

“…Il est fonction du pourcentage de surface articulaire touchée et de la présence d'un déplacement. En effet, la présence d'une fracture marginale postérieure semble être responsable d'une augmentation significative des complications arthrosiques dans les atteintes de la pince bimalléolaire, même en cas de petits fragments marginaux postérieurs [7][8][9]. Cette fracture a donc un fort potentiel arthrogène, surtout en cas de retards diagnostique et thérapeutique, car c'est une fracture articulaire concernant un fragment osseux mal vascularisé (aucun muscle ne s'insère sur cette face postéro-inférieure du tibia).…”