Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture

Mitchell, Phillip M.; Harms, Kelly A; Lee, Adam K.; Collinge, Cory

doi:10.1097/bot.0000000000001398

Cited by 27 publications

(28 citation statements)

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“…The practicality and accuracy of fracture mapping have been reported in a number of studies investigating scapula bone fractures, tibial plateau fractures, radial head fractures, and ulnar pulley articular fractures [21][22][23][24]. The radial fracture map developed in this current study can also be used to assess existing fracture classification systems.…”

Section: Discussionmentioning

confidence: 83%

Melone’s concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping

Zhang

Wang

et al. 2020

J Orthop Surg Res

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Background: There is no consensus in the literature about the ideal classification of the distal radius fracture for the clinical practice. The traditional Melone classification system divides the distal radius into four basic components, the shaft, radial styloid, dorsal medial fragment, and volar medial fragment. The aim of this study was to identify fracture lines in comminuted distal radius fractures using three-dimensional mapping of computed tomography (CT) images to test the hypothesis that fracture fragments can be divided according to the Melone classification. Methods: Fifty-nine consecutive OTA/AO 23C3 fractures presented at the hospital between January 2018 and October 2019 were retrospectively reviewed. The fracture lines were characterized in the axial, sagittal, and coronal CT planes. After reducing the fractures in a three-dimensional (3D) model, the fracture lines were plotted from the CT images and were then superimposed on one another and oriented to fit a standard template. The area of articular surfaces was measured and compared to quantify the differences between the radial bone fragments. Results: Thirty-five cases (59.3%) in this study fit the Melone classification and 24 cases (40.7%) did not. On the radiocarpal surface, there was a greater concentration of fracture lines in the dorsal area of the radius than in the volar area. On the distal radioulnar joint (DRUJ), the fracture lines were focused around two specific concentrated regions. For the articular surface area, the mean area of the radial styloid, volar medial fragment, and dorsal medial fragment was 141.13 ± 90.16 mm 2 , 147.79 ± 75.94 mm 2 , and 79.05 ± 70.73 mm 2 , respectively. There was a significant difference in articular surface area for the Melone fragments (P = 0.002). Conclusions: The Melone classification system is not suitable for characterizing all C3 fractures. The findings of this study confirm that the dorsal medial fragments are relatively comminuted and small. Extra care should be given to these small fragments when reducing the fracture.

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Section: Discussionmentioning

confidence: 83%

Melone’s concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping

Zhang

Wang

et al. 2020

J Orthop Surg Res

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“…Based on a CT scan or MRI, the mean incidence was 70% (56–88.2%) and 70.4% (35.7–92.3%), respectively [ 2 – 8 ]. Only one study provided the incidence of PMFs in patients with mid-distal spiral TSFs, which was 48.8% based on CT scans (Table 2 ) [ 9 ]. For patients with distal third TSFs, the mean incidence of PMFs was 28.2% based on radiographs and 33.4% based on CT scans [ 3 , 8 , 13 , 25 , 26 ].…”

Section: Resultsmentioning

confidence: 99%

“…In recent years, TSFs combined with ankle fractures have attracted increasing attention in clinical practice [ 9 , 28 ]. Indeed, as early as 1946, Lauge-Hansen [ 29 ] first recognized the combination of TSFs and additional posterior malleolar injuries.…”

Section: Discussionmentioning

confidence: 99%

“…Tibial shaft fractures (TSFs), especially spiral TSFs or distal third spiral TSFs, are often associated with posterior malleolar fractures (PMFs) and have been reported in several series [ 1 – 9 ]. However, non-displaced PMFs may be overlooked or underdiagnosed during the diagnosis and treatment of obvious TSFs (Fig.…”

Section: Introductionmentioning

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 ].…”

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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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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Morphology of the Posterior Malleolar Fracture Associated With a Spiral Distal Tibia Fracture

Cited by 27 publications

References 10 publications

Melone’s concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping

Melone’s concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping

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

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