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

Wang, Zhongzheng; Chen, Wei; Zhu, Yanbin; Tian, Siyu; Zhao, Kuo; Guo, Jialiang; Hou, Zhiyong; Zhou, Qi Tony

doi:10.1186/s13018-021-02502-6

Cited by 12 publications

(9 citation statements)

References 46 publications

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“…It has been found that the identification of posterior ankle injuries is important for correct preoperative planning and appropriate postoperative physical therapy. During treatment of tibial fractures, neglecting posterior ankle fractures may result in iatrogenic displacement [ 8 , 9 ]. Early identification of patients with tibial fractures combined with occult posterior ankle fractures can prevent posterior ankle fractures during intramedullary nailing or postoperative further displacement due to insufficient protection [ 10 , 11 ].…”

Section: Discussionmentioning

confidence: 99%

Incidence and Predictive Factors of Tibial Fracture with Occult Posterior Ankle Fractures

Wang

Yang

Dong

et al. 2021

Journal of Healthcare Engineering

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Background. Few studies exist on the predictive factors of tibial fractures with hidden posterior ankle fractures. Objective. To study the incidence and predictive factors of tibial fractures with occult posterior ankle fractures. Methods. Tibial fracture patients were prospectively selected who were admitted to our hospital from January 2016 to May 2021 and their general clinical data, X-ray images, CT images, and other imaging data were collected and then divided them into posterior malleolus fracture group and nonposterior malleolus fracture group according to the presence or absence of posterior malleolus fractures. Multivariate regression analysis and receiver operating curves (ROC) were performed to analyze the influencing factors of tibial fracture with occult posterior ankle fracture. Results. CT showed that 25 (13.44%) patients had occult posterior ankle fractures among 186 patients with tibial fracture. There was no significant difference in gender, age, and locations of tibial fracture between the two groups ( P > 0.05 ). There were statistical differences in the types, locations, and lengths of patients with tibial fracture but without posterior malleolus fractures. The length of the tibia fracture group was significantly lower than the tibia with posterior ankle fracture group ( P < 0.05 ). Logistics regression analysis showed that tibial fracture with occult posterior ankle fracture was not significantly correlated with gender, age, and location of tibial fracture ( P > 0.05 ), but was significantly correlated with tibial fracture type, location, and length (HR = 1.830, P = 0.035 ; HR = 5.161, P = 0.004 ; HR = 1.126, P = 0.030 ). The ROC curve showed that the AUC of length of tibial fracture with occult posterior ankle fracture was 0.599. The YD index suggested that the best cut point for the prediction of tibial fracture with occult posterior ankle fracture was above 13.18%. The sensitivity and specificity of spiral tibial fracture and distal 1/3 tibial fracture for prediction were 88.00% and 63.35%, 92.00%, and 58.39%, respectively, which was significantly higher than that of tibial fracture length ( P < 0.05 ). Conclusion. Patients with tibial fractures have a higher incidence of occult posterior ankle fractures. Spiral tibial fractures and distal 1/3 tibial fractures have a higher predictive value for tibial fracture with occult posterior ankle fractures and can help clinical detection as soon as possible, which is a more accurate and appropriate treatment.

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Section: Discussionmentioning

confidence: 99%

Incidence and Predictive Factors of Tibial Fracture with Occult Posterior Ankle Fractures

Wang

Yang

Dong

et al. 2021

Journal of Healthcare Engineering

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“…Ankle fractures include fractures of the posterior malleolus or Volkmann's malleolus, which is observed in up to 46% of AO/ASIF type B and C fractures (5,23) . However, recent studies have shown that nondisplaced posterior malleolus fractures may be missed or underdiagnosed in many patients, leading to iatrogenic displacement during surgery and permanent ankle damage (24)(25)(26)(27) . Furthermore, in the last ten years, published studies using additional CT and MRI examinations have shown that the incidence of posterior malleolus fractures associated with other tibial fractures increases considerably and are highly under-diagnosed if studied using plain radiographs.…”

Section: Discussionmentioning

confidence: 99%

“…Finally, Bartoníček et al (20) recently concluded that appropriate diagnosis, classification, and treatment require preoperative CT scan, preferably with three-dimensional reconstructions. This is because today, the three-dimensional contour of the fragments, the involvement of the notch, the presence of joint impaction, and intercalated fragments interposed in the fracture line seem to have greater therapeutic relevance than the fragment size and the extension of the fractured articular surface (8,20,24,31) . Our study observed that most patients who do not present preoperative CT are treated by the AP approach (Group 1), which agrees with the patients in the first years of the study.…”

Section: Discussionmentioning

confidence: 99%

Does the posterior approach offer advantages in short-term in trimalleolar ankle fractures?

Holgado-Fernandez¹,

Galindo-Juárez²,

Muñiz-Zatón³

et al. 2022

J Foot Ankle

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Objective: The aim of this study was to compare the early (nine months after surgery) synthesis of the posterior malleolus by direct posterior (P) approach versus the percutaneous anteroposterior (AP) screw in trimalleolar ankle fractures to analyze the early clinical status of the patient (eight months) by studying the American Orthopedic Foot And Ankle Society (AOFAS) scale to compare postsurgical clinical recovery between both approaches, the rate of hospital days in both groups, the quality of joint reduction by computed tomography (CT) study and the rate of most frequent complications (fibular tendinopathy and surgical wound). Methods: A retrospective comparative study was performed between 2016-2020, including 94 patients with trimalleolar ankle fracture type 44-A/B/C (27 percutaneous AP surgical treatment and 67 P approach). Both groups were compared by analyzing demographic variables, clinical-functional status, radiological variables, and complications. Statistical analysis was performed using SPSS-20, with a p-value of 0.05 as significance. Results: Demographically, both groups were comparable, not finding significant differences between them. An increase in the days of admission before surgery was observed in the P approach with a mean of 4 (p=0.001). No significant clinical differences were found in the AOFAS scale, with a mean of 85 in both groups. Regarding the radiological result, a better reduction was observed with P approach (good=57, fair=9, poor=0) compared to the AP approach (good=10, fair=7, poor=9) (p=0.001). As for the complications, no significant differences were observed for the surgical wound. However, a higher need for fibular plate removal could be observed with P approach (n=17) (p=0.046). Conclusions: Clinically, both groups observed no significant differences through the AOFAS scale. The posterolateral approach has a higher rate of hospital days before surgery. Radiologically, a better joint reduction is achieved by a direct approach to the posterior fragment. Level of Evidence III; Retrospective Comparative Study.

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“…These include several retrospective studies with small samples sizes, with variable diagnostic reporting explaining the high degree of variability in prevalence. Wang et al published a systematic review on the incidence of missed diagnosis of occult PMF associated with tibial shaft fractures, finding that approximately 50% were missed on plain radiographs alone [10]. The presence of occult PMFs is of importance when treating tibial shaft fractures as there is an increased risk of intra-operative displacement if the tibia is fixed prior to the posterior malleolus [11].…”

Section: Introductionmentioning

confidence: 99%

“…Multiple authors have highlighted the increased incidence of occult PMFs with spiral tibial shaft fractures, although other reported associated risks of intra-articular extension have been limited [8,10]. Hendrikx et al have developed a machine learning predictive model to help highlight factors that may determine PMF associations with tibial shaft fractures [12].…”

Section: Introductionmentioning

confidence: 99%

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension

Myatt

Stringer

Chapman

et al. 2022

Eur J Trauma Emerg Surg

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Background Multiple authors have highlighted the increased incidence of occult posterior malleolar fractures (PMFs) with spiral tibial shaft fractures, although other reported associated risks of intra-articular extension have been limited. The aim of our study is to investigate both PMFs and non-PMFs intra-articular extensions associated with tibial diaphyseal fractures to try to determine any predictive factors. Methods We undertook a retrospective review of a prospectively collected database. The inclusion criteria for this study were any patient who had sustained a diaphyseal tibial fracture, who had undergone surgery during the study period and who had also undergone a CT scan in addition to plain radiographs. The study time period for this study was between 01/01/2013 and 9/11/2021. Results Out of 764 diaphyseal fractures identified, 442 met the inclusion criteria. A total of 107 patients had PMF extensions (24.21%), and a further 128 patients (28.96%) had intra-articular extensions that were not PMF’s. On multivariate analysis, spiral tibial fracture subtypes of the AO/OTA classification (OR 4.18, p < 0.001) and medial direction of tibial spiral from proximal to distal (OR 4.38, p < 0.001) were both significantly associated with PMF. Regarding intra-articular fractures, multivariate analysis showed significant associations with non-spiral (OR 4.83, p < 0.001) and distal (OR 15.32, p < 0.001) tibial fractures and fibular fractures that were oblique (OR 2.01, p = 0.019) and at the same level as tibia fracture (OR 1.83, p = 0.045) or no fracture of the fibular (OR 7.02, p < 0.001). Conclusion In our study, distal tibial articular extension occurs in almost half of tibial shaft fractures. There are very few fracture patterns that are not associated with some type of intra-articular extension, and therefore, a low threshold for preoperative CT should be maintained. Level of evidence 4.

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

Cited by 12 publications

References 46 publications

Incidence and Predictive Factors of Tibial Fracture with Occult Posterior Ankle Fractures

Incidence and Predictive Factors of Tibial Fracture with Occult Posterior Ankle Fractures

Does the posterior approach offer advantages in short-term in trimalleolar ankle fractures?

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension

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