The Journal of Bone and Joint Surgery (American). 2006;88:1085-1092.
doi:10.2106/JBJS.E.00856
© 2006 The Journal of Bone and Joint Surgery, Inc.
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Pathoanatomy of Posterior Malleolar Fractures of the Ankle

Naoki Haraguchi, MD1, Hiroki Haruyama, MD2, Hidekazu Toga, MD3 and Fumio Kato, MD4

1 Department of Orthopaedic Surgery, West Tokyo Metropolitan Police Hospital, 4-8-1 Nishimotomachi, Kokubunji-shi, Tokyo 185-0023, Japan. E-mail address: naokihg{at}aol.com
2 Haruyama Hospital for Surgery, 1-24-5 Hyakunincho, Shinjuku-ku, Tokyo 169-0073, Japan
3 Department of Orthopaedic Surgery, Tokyo Metropolitan Police Hospital, 2-10-41 Fujimi, Chiyoda-ku, Tokyo 102-8161, Japan
4 Deceased

Investigation performed at the Tokyo Metropolitan Police Hospital and the Haruyama Hospital for Surgery, Tokyo, Japan

NOTE: The authors thank Dr. Eric M. Bluman and Mr. Robert S. Armiger for their helpful advice and suggestions and Ms. Elaine P. Henze for her editorial assistance.

The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: The functional outcome following ankle fractures that involve a posterior malleolar fragment is often not satisfactory, and treatment of this type of fracture remains controversial. Thorough knowledge of the pathologic anatomy of the posterior malleolar fracture is essential for planning appropriate treatment. Thus, we conducted a computed tomographic study to clarify the pathologic anatomy of the posterior malleolar fracture.

Methods: Between 1999 and 2003, fifty-seven consecutive patients with a unilateral ankle fracture with one or more posterior fragments were managed at our hospital. We reviewed the patients' preoperative computed tomographic scans to determine (1) the ratio of the posterior fragment area to the total cross-sectional area of the tibial plafond and (2) the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond.

Results: The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). Two of the eleven medial-extension fractures extended to the anterior part of the medial malleolus, and the other nine actually consisted of two fragments. The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus varied.

Conclusions: The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. The information obtained from this study will be helpful for conducting basic research of this condition and for determining appropriate surgical approaches.


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