Medial malleolar fractures

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512–521.

The Reliability and Accuracy of the Medial Malleolar Fracture Classification Based on 3D CT Reconstruction

“…Fourth, the Herscovici classification would be deemed unclassifiable due to the atypical height and direction of fracture lines or comminution of fracture sites 8 . Carter et al 6 . also recognized the limitation of the Herscovici classification and suggested modifying it by considering a lateral X‐ray or CT scan.…”

“…Fourth, the Herscovici classification would be deemed unclassifiable due to the atypical height and direction of fracture lines or comminution of fracture sites. 8 Carter et al 6 also recognized the limitation of the Herscovici classification and suggested modifying it by considering a lateral X-ray or CT scan. We found moderate interobserver (k = 0.46), substantial intraobserver (k = 0.67) reliability, and 71.8% accuracy for the Herscovici classification, as well as substantial interobserver (k = 0.64), intraobserver (k = 0.74) reliability, and 81.4% accuracy for the new classification system.…”

“…1,2 Ankle fractures (42.6%) have a medial malleolar component, which plays an important role in the configuration and stability of ankle joints. 3,4 The current standard classification of medial malleolar fractures is the Herscovici classification, [5][6][7] which divides medial malleolar fractures into four types according to the anteroposterior radiograph: type-A, avulsion fracture at the tip of medial malleolar; type-B, a fracture located between the tip and tibial plafond; type-C, a fracture located at the level of plafond; and type-D, a fracture extended vertically to the metaphyseal region (Fig. 1, Table 1).…”

“…Aitken et al 8 evaluated the reliability and reproducibility of the Herscovici classification and found it with moderate interobserver reliability (k = 0.54, 95% CI 0.40-0.68), substantial intraobserver reliability (k = 0.64, 95% CI 0.51-0.79), and moderate accuracy (k = 0.54, 95% CI 0.40-0.66). Some authors 6,8,9 suggested refining the Herscovici classification system because the fracture patterns of medial malleolus were intricate, and 26% of cases were difficult to identify based on the Herscovici classification.…”

Effect of buttress plate in Herscovici type D vertical medial malleolar fractures and peripheral fractures: a retrospective comparative cohort study

“…Due to the special anatomy and injury mechanism of the medial malleolus, the fracture of the medial malleolus has a complicated condition, among which the supination-adduction injuries are even more difficult to treat. Low lateral malleolus fracture or lateral collateral ligament injury can result in vertical split fracture of medial malleolus, and compression fracture of the distal medial articular surface of tibia may occur [ 4 , 5 ]. This fracture pattern is relatively rare, accounting for 12.2% to 21.1% of ankle fractures [ 6 ].…”