Posterior Malleolar Ankle Fractures

Abstract

Background: There is increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. We report our results of posterior malleolar fracture management based on the classification by Mason and Molloy. Methods: All fractures were classified on the basis of computed tomographic (CT) scans obtained preoperatively. This dictated the treatment algorithm. Type-1 fractures underwent syndesmotic fixation. Type-2A fractures underwent open reduction and internal fixation through a posterolateral incision, type-2B fractures underwent open reduction and internal fixation through either a posteromedial incision or a combination of a posterolateral with a medial-posteromedial incision, and type-3 fractures underwent open reduction and internal fixation through a posteromedial incision. Results: Patient-related outcome measures were obtained in 50 patients with at least 1-year follow-up. According to the Mason and Molloy classification, there were 17 type-1 fractures, 12 type-2A fractures, 10 type-2B fractures, and 11 type-3 fractures. The mean Olerud-Molander Ankle Score was 75.9 points (95% confidence interval [CI], 66.4 to 85.3 points) for patients with type-1 fractures, 75.0 points (95% CI, 61.5 to 88.5 points) for patients with type-2A fractures, 74.0 points (95% CI, 64.2 to 83.8 points) for patients with type-2B fractures, and 70.5 points (95% CI, 59.0 to 81.9 points) for patients with type-3 fractures. Conclusions: We have been able to demonstrate an improvement in the Olerud-Molander Ankle Score for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Mason classification type-3 fractures have marginally poorer outcomes, which correlates with a more severe injury; however, this did not reach significance. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Traditional Approach vs Posterior Approach for Ankle Fractures Involving the Posterior Malleolus

“… 9 , 10 , 33 , 35 , 44 , 55 Other authors recommend ORIF of all PMFs regardless of their size as this this was found to reduce the need for syndesmotic fixation and improve outcomes in their study. 3 , 23 , 29 , 30 The subanalyses of patients with PMF smaller than 25% in the current study displayed similar SEFAS scores between treatment groups, although fragments were fixed in group A and no fixation was performed in group B. There was a trend of better results in group B.…”

“…Compared to the normative values of SEFAS, 8 our results of median 36 for group A and 40 for group B reflect the serious impact on function and quality of life of an ankle fracture involving the posterior malleolus. Mason et al 29 also reported low PROM scores in patients with posterior malleolus fractures, with a mean Olerud-Molander Ankle Score of 74.1. Xu et al 56 found an average American Orthopaedic Foot & Ankle Society (AOFAS) score of 95.9 in a similar population.…”

“… 52 Despite lack of solid evidence, there has been a trend toward use of a posterior approach allowing open reduction and internal fixation (ORIF). 13 , 20 , 29 It is advocated that this approach allows more anatomical reduction of the PMF and fixation of fragments smaller than 25%. 48 In addition, fixation of the distal fibular fracture through the same incision gives good soft tissue coverage by the peroneal muscles.…”

Posterolateral Approach to Posterior Malleolar Fractures: A Literature Review

“…We believe characterizing the fracture pattern, utilizing the Mason and Molloy classification, will help plan a stable fixation strategy. 9,38,39 We have found that those with a Mason and Molloy classification type 1, type 2a, and posterolateral portions of 2b can effectively be approached by a posterolateral approach. The posteromedial portion of type 2b's are best approached by a medialposteromedial approach and type 3s are best approached by a posteromedial approach.…”

Current management of trimalleolar ankle fractures

“… 121 According to the Mason classification, Mason Type 2 and 3 posterior malleolar fractures are treated with a posterolateral approach and only Type 1 fractures with trans-syndesmotic fixation. 125 The posterolateral approaches allow open reduction and internal fixation of the posterior malleolus as well as the treatment of distal fibular fractures. 99 Open reduction and internal fixation of the posterior malleolus can be performed with posterior screw or plate fixation depending on the fracture configuration and bone quality.…”