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PMID: 16467626 Clin Orthop Relat Res. 2006 Jun;447:165-71.

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Fixation of posterior malleolar fractures provides greater syndesmotic stability.

Gardner MJ Brodsky A Briggs SM Nielson JH Lorich DG.

Gardner MJ, CORR 2006

Pubmed

Syndesmotic injuries are common in ankle fractures. Traditional syndesmosis fixation may be associated with a secondary procedure. When the posterior malleolus is fractured, the posterior syndesmotic ligaments may remain intact and attached to the fragment. Our goals were to establish the incidence of syndesmotic ligament ruptures in pronation-external rotation type ankle injuries associated with posterior malleolar fractures, and to assess syndesmotic stability after fixation of the posterior malleolus compared with using a syndesmotic screw. Fifteen patients who sustained pronation-external rotation Stage 4 ankle fractures that involved the posterior malleolus were evaluated using radiographs and magnetic resonance imaging. No complete tears of the posterior-inferior tibiofibular ligament occurred. A pronation-external rotation fracture pattern with a posterior malleolar fragment was created in 10 lower extremity cadaver specimens with random fixation of the posterior malleolus or the syndesmosis. Compared with the intact specimens, stiffness was restored to 70% after fixation of the posterior malleolus, and to 40% after syndesmosis stabilization. Syndesmotic stability may be obtained more effectively by fixation of the posterior malleolus rather than by using a syndesmotic screw. Although additional clinical investigation is warranted, these concepts may be useful in eliminating syndesmotic screw fixation in select patients.

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(SBQ18FA.21) Figures A-C are the radiographs of a 26-year-old male who presents to the emergency department following a motocross accident. Two attempts at a closed reduction by the on-call orthopedic resident were unsuccessful. Figures D and E are the pre-operative axial CT-images that were obtained. The patient undergoes surgical fixation seen in Figure F. Limitations in post-operative dorsiflexion is likely influenced by which of the following?

QID: 211330

FIGURES:

A
B
C
D
E
F

Type & Select Correct Answer

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Fracture extension to the posteromedial rim

15%

(280/1885)

Initial displacement of the fibula fracture

16%

(295/1885)

Posterior fixation of the fibula and posterior malleolus

38%

(710/1885)

Initial talar subluxation

15%

(281/1885)

Inability to reduce the ankle

16%

(299/1885)

Select Answer to see Preferred Response

SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic

(SBQ18FA.19) A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. His radiograph is shown in Figure A. Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. All of the following are true regarding posterior malleolar fixation EXCEPT:

QID: 211308

FIGURES:

A

Type & Select Correct Answer

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Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases

15%

(326/2213)

Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation

62%

(1366/2213)

Functional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixation

9%

(204/2213)

Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation

7%

(145/2213)

The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture

6%

(142/2213)

Select Answer to see Preferred Response

SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic

(SBQ18FA.18) A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. The injury is closed, and the patient is neurovascularly intact. Injury films are shown in Figures A and B. An unsuccessful attempt at reduction in the emergency department with sedation was made. What is the cause of failure of closed reduction?

QID: 211297

FIGURES:

A
B

Type & Select Correct Answer

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Subacute nature of fracture

1%

(13/2015)

Incarceration of the deltoid ligament

15%

(295/2015)

Incarceration of the fibula behind the posterolateral ridge of tibia

67%

(1340/2015)

Entrapment of the flexor hallucis longus (FHL) tendon

15%

(304/2015)

Entrapment of the extensor digitorum brevis (EDB)

3%

(53/2015)

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SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic

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