Addressing Posterior Malleolar Ankle Fractures

Nicholas Todd, DPM, AACFAS, Meagan Jennings, DPM, FACFAS, Shannon Rush, DPM, FACFAS, Ryan Wood, DPM, and Richard Jensen, DPM, FACFAS

   When the patient went to surgery, there were no associated fracture blisters and the skin was intact. Due to the presence of the large posterior medial fragment, surgeons decided to utilize a posterior medial approach in conjunction with a standard lateral approach.

   For surgery, the patient was in the prone position with a thigh tourniquet. Surgeons fixated the fibula first, utilizing a contoured posterior plate because of the significant comminution. After obtaining anatomic length, they created a posterior medial incision. Creating exposure through a surgical plane between the posterior tibial tendon and flexor digitorum longus allowed for direct visualization of the distal tibia. Throughout the medial exposure, one should take care to retract the neurovascular bundle. A two-hole plate (utilized in antiglide fashion) secured the main posterior fragment. Once the main posterior fragment was stable, the surgeons stabilized the posterior medial fragments utilizing a combination of screws and plates. They admitted the patient for pain control and therapy for 48 hours.

   The patient was discharged on low molecular weight heparin for deep vein thrombosis prophylaxis and oxycodone for pain control. The patient was in a non-weightbearing cast for five weeks. At week six, the patient started wearing a walking boot and got instructions on range of motion exercises. At week eight, the patient transitioned to regular shoes with an ankle brace. At the 12-week mark, the patient was able to ambulate in a standard shoe and resume activities.

Case Study Three: When A Patient’s Fall Leads To A Posterior Malleolar Fracture With A Distal Fibular Fracture

A police officer in her early 40s fell down the stairs while at work. The patient immediately went to the emergency room where X-rays revealed a posterior malleolar fracture along with a distal fibular fracture. On the lateral radiograph, the posterior malleolar fracture appeared to comprise 20 percent of the articular surface. A CT scan revealed a fracture fragment that involved a large posterior fracture including a significant portion of the tibial plafond. The main fracture fragment was lateral in relation to the tibial plafond.

   The patient went to surgery five hours following the injury. Utilizing the CT imaging, the surgeons decided to use a posterior lateral approach. The patient was in the prone position for the surgical exposure. The surgeons made the incision within the interval between the Achilles tendon and the peroneal tendons. During the exposure, they encountered the sural nerve and carefully retracted it. They mobilized and fixated the posterior malleolar fracture with a one-third tubular plate in an antiglide fashion and two 3.5 mm interfragmentary screws. Surgeons provided fixation of the fibular fracture through the same incision with a solitary plate in antiglide fashion. (It should be noted that fixation for the posterior malleolus occurred first with this posterior lateral approach. If the surgeon fixes the fibular first, it can be difficult to reduce the posterior fracture fragment.)

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