Thank you for allowing me to participate in this wonderful online meeting. Again, thanks to the committee and Dr. Mangione for involving me. I was asked to speak on posterior malleolus fractures, a new appreciation. First of all, as an introduction, my name is Jason Rudolph. I'm an orthopedic surgeon. I've been practicing in private practice for 20 plus years now. I completed a fellowship in trauma as well as foot and ankle. My practice over the years has now basically become a primarily lower extremity trauma, sports and reconstruction practice. And rather than doing a purely didactic lecture, I was hoping to pass along some tips and tricks that I've learned along the way. This is where I'm from, the Lehigh Valley of Pennsylvania, which is essentially halfway between New York City and Philadelphia. We include the Pocono Mountains. So it's a fairly large region of over a million people. So we do get to see a fairly complex and mixed variety of patients. To jump right in, fractures to the posterior rim of the tibia or the posterior malleolus can occur in up to 50% of ankle fractures. Classically, it was taught that if the fracture involved one third or greater of the articular surface, then it should be fixed. This classic treatment was essentially based on a 1940s report of eight cases. And I believe it was in the Journal of Gynecology of all places. To date, there's still no complete consensus on the best treatment for these fractures. However, with their increasing use of CT or advanced imaging, we've come to understand the fracture patterns a little bit more completely. This allows for a more individualized approach to each fracture, not one that is completely contained, but one that I think we can apply across the spectrum of different presentations. So my first tips and tricks that I'm gonna try to apply here is that due to the high frequency of unstable posterior malleolar fractures, I now do CAT scan almost every bimalleolar fracture or isolated lateral malleolar fracture with medial space widening. And if possible, do this in the emergency department. If they come to the office, then of course we try to get a quick CT scan from the office. I am a personal fan of the gravity stress view to determine medial space widening. And of course, if there's a medial malleolar fracture and medial space widening and a potential for a lateral posterior malleolar fracture, I do go to a CT scan. Briefly talking about the anatomy, which most of us are fairly comfortable with, the distal end of the tibia is a concave structure. The posterior malleolus projects further distally than the anterior rim. The groove containing the posterior tip tendon delineates the medial malleolus from the medial portion of the posterior malleolus. And this is the important thing, this posterior malleolus, and I'll circle it over in here. This is the extensive coverage of that posterior tibial fibular ligament, which is felt to provide at least 42% of the total strength of the synosmosis. And clearly that's where that stability comes from when things start subluxating or dislocating posteriorly. To get into some of the classifications, the Haraguchi classification of fractures. Type I fracture is a posterior lateral oblique fracture, which creates essentially a triangular fragment. This is the most common type. Type II is a medial extension fracture involving any part of the medial malleolus. And type III is a shell fracture of the posterior cortex. This classification does certainly help. It's one of the simpler classifications. This is the classification that I think many of us are leaning towards now, a Mason-type classification, which is based on the severity of the injury. Type I is the small avulsion-type fracture due to the tension fractures of that posterior inferior tibiofibular ligament, as delineated in this picture here, type I. Type IIa is a large posterior triangular-shaped wedge with a single lateral fragment, again, similar to that Haraguchi I. Type IIbs are a special type, and this we'll get into later. The special type has two components and sometimes a comminuted component. Both fragments are medial and lateral and sometimes more comminuted fragment. And type III is a complete posterior separation of the tibial component with a large triangular fragment, many times associated with a high fibular fracture as well. This is a more enlarged picture, again, showing the type I's, type II's, type III's, where there's two parts, and type IV's. And you see how this is really a CT scan-based classification. These are some x-rays that I downloaded from a nice article, review article, showing the type I, which is the small sort of shell fragment just with the attachment of the syndesmotic ligament. Type IIa, which is a larger triangular fragment with no extension towards that medial piece. The IIb is this classic two-piece fragment. And finally, the type III, the large, almost a posterior pilon-type fracture involving the posterior aspect of the distal tibia intrarticularly. So my feeling about this classification as compared to many of our classifications we deal with on a daily basis, this one not only helps in the decision-making for surgery, but also helps in determining the appropriate surgical approach to that fragment. So surgical indications, again, the original indications, 25 to 33% joint involvement with a two-millimeter step-off. I think now we've understood that this is based on a very small sample size, and that now we wanna look at this more as what goals can we achieve surgically? So our goals are now based on understanding of the three-dimensional pathoanatomy of the distal tibia. One, restoring the articular congruity of the distal talus and maintaining tailored containment. Two, bony restoration of that syndesmosis, getting the PITFL in its anatomic position. And finally, restoring the fibular notch so as there's no creation of distal tibiofibular post-traumatic arthritis. So these indications do still remain somewhat nebulous and highly variable. Generally, it's agreed upon that any fracture for having greater than 25% should be fixed, and the decision should really based on ankle instability and tailor reduction. A pearl that I was taught back in my training days at Vanderbilt University in my trauma fellowship was, if the ankle is subluxating or dislocating posteriorly, focus your attention where those forces were and focus on really rigidly fixating the posterior ankle. So here are some proposed guidelines from a great review article. Non-operative management for any type I avulsion fracture, but consider synesthematic fixation. Again, this is a small fragment, but if 42% of the strength of the synesthesmosis is through that small fragment, if you can't fix the fragment, at least fix the synesthesmosis. Non-operative management of any non-displaced type II and III fractures with open reduction and direct fixation for displaced type II and III fractures or any impacted fractures. I think the current teaching is leaning more towards direct reduction of these fractures rather than indirectly reducing it from the front or through the fibular fracture, for instance. And of course, open reduction and internal fixation of all type IV or large triangular, essentially intra-articular pilon fractures. This is a nice table sort of stating the same thing I just discussed, the type I extra incisional fractures non-operatively. Posterolateral approaches, which is around direct fixation of the posterolateral fragments, two-part fragments considering posterolateral or posteromedial or both, and the large triangular fractures fixing either directly from posterolateral or potentially indirectly with a transfibular assistance of the reduction. So discussing the approaches, which does take some getting used to. Placing the patient prone and the posterolateral is really the workhorse approach here. This approach does allow access to the posterior aspect of the fibula, the posterior incisura, as well as the posterolateral tibia, and really does allow access to that posterolateral tibia. Reaching the far posteromedial fragments does become difficult and requires a different approach. The approach is halfway between the Achilles and the posterior edge of the fibula. Key nerve defined directly at the beginning is that sural nerve. You want to find the interval between the FHL and the peroneal tendons, and access the tibia by simply elevating the FHL medially. This allows protection of the neurovascular bundle medially, and really lets you look directly down in most of these fracture fragments. This is the approach used for both 2A and the type 3 fractures. And the diagram over here on the right is trying to display this in the anatomical model. Posteromedial approaches. Again, patient is in the prone position. The majority of the posterior tibia can still be visualized. The skin incision now is just medial to the Achilles tendon. And now by pulling the Achilles tendon laterally, we still use that FHL to retract medially to protect the neurovascular bundle. This is an approach that's nice for the 2Bs and certainly the 3 fractures. Medial-posteromedial approach. This is again done prone or potentially supine. The approach is directly along the posterior medial edge of the tibia. In this case, the posterior tibial tendon is going to be retracted posteriorly protecting the neurovascular bundle. And this is useful for those much more rare fractures, but certainly out there where there's a posterior medial fracture with the apex exiting medially. Now, what about those other malleolar fractures, the fibular and the medial malleolar fractures? These are usually approached through separate incisions, unless that fibular fracture is more distal and still can be accessed through the posterolateral approach. Once you have fixated the tibia and you look towards the fibula, the perineal muscles and tendons can be retracted medially, now allowing you to visualize those more distal fractures. If the fracture is more proximal, certainly take your time and flip the patient supine and go from the way you're used to going. This is a little bit of a complicated picture, but trying to display the approach for the medial-posteromedial. The posteromedial approach, again, through the medial side of the Achilles, posterolateral between the Achilles and the perineal muscles. Fixation techniques. So this is our standard AO techniques. It can be done with either cannulated, partially threaded lag screws, with or without washers. Bicortical technique with young, healthy bone and a good anterior cortex. And using posterior buttress plates certainly adds to stability. Some of the very, very distal type 1 fractures or type 2a fractures really, it becomes more difficult to actually fit a posterior buttress plate and sometimes two screws is really all that's available. This is a special consideration for the Mason type 2b fragments. This is where there's essentially a T fracture of that posterior malleolus, first with the posteromedial and second with the posterior lateral fracture. The key here is you want to fix the posterior medial fragment first. If you fix the posterior lateral fragment first, it can push the medial fragment out of the way and not allow a reduction as displayed in this picture here. So here, if you tried to fix the wrong fragment first, you'd be stuck. So always try to fix that posterior medial fragment first, that's displayed here in one, followed by the posterior lateral fragment in two. So a few of my tips and tricks to approaching these. We have these great sterile sheets that I use and I'll wrap a sheet with a co-band and place that directly under the ankle. I don't love working with the ankle or the forefoot hanging off the end of the bed. I try to put the patient just a little bit more proximally and then place a nice bump under the anterior ankle. If you have one of the great C-Armor devices that lets you transition back and forth from AP to lateral quickly, that's nice. Otherwise a sterile sheet because you are definitely going back and forth between AP and lateral x-rays quite frequently. I found that the dental pick is an essential device to help pull that long triangular fragment into its anatomic position prior to placing the K-Wires for your camelator screw fixation. Of course, you realize that most of this reduction is indirect. You're not seeing the articular cartilage directly. Therefore you're going for an anatomic reduction of the fragment that you can see and then using C-Arm to judge your rotation. Sometimes with the small intra-articular fragments, I found that I can get that freer elevator at the fracture site, slip it in from just anterior to the fracture, disimpact and reduce the fragments and then use my dental pick and followed by the K-Wires to fixate that posterior fragment. And of course, always be prepared to flip the patient to access those higher fibular fractures and the medial malleolar fractures. I mean, it is working upside down in a cave sometimes. So sometimes it's nice just to be prepared to flip the patient, take the time, reprep and drape and approach those complicated medial malleolar fractures from the anteriorly where most of us are more comfortable. Outcomes are very, very variable here. It's generally accepted that ankle fractures with posterior malleolar fracture involvement have worse general functional outcomes. Some quick references, there's been worse long-term outcome with 5% or greater of the joint involvement. So almost any posterior malleolar fracture has a generally poorer outcome. Anatomic reduction of the fragments greater than 10% had better VAS scores than not. And unstable ankles with syndesmotic injuries and posterior malleolar fractures actually had similar outcomes when the posterior malleolar fragment was fixed or when the syndesmosis was repaired. So that's the end of my didactic portion of the lecture. I was now going to move into a few cases. The first case is an 18-year-old female, trampoline injury presented with a trimalleolar fracture and a Mason 2A type fracture of the posterior malleolus. So to get to her x-rays, this is the x-ray that she presented to the office with. You see, she's subluxating posteriorly. So again, classic training that I was fortunate to be involved with, recommended going posteriorly anytime something is unstable posteriorly. This is the CT scan. I'm sorry, it's a little blurry, but it does display this posterior lateral non-split distal fragment. We can see it again on the sagittal. There is a smaller intraarticular component here, but because this was an 18-year-old young lady, there was a displaced fragment here. I did elect to go posteriorly first, and then I did flip her to go take care of that medial malleolar fragment. So I don't have intraoperative pictures here, but in this case, due to the size of that fragment, I elected to use two screws initially to fixate the posterior lateral fragment, flipped her supine, and fixed the comminuted medial and lateral malleolar fragments. And that's the AP. Of course, you keep most of these lateral films without the fibular plate, so you can truly see the articular cartilage. Once the lateral plate goes in, you're not really able to observe that nice articular surface as well. And this is her in the office a week later, just to show you the incision to orient you. That's the heel. Those are the toes. That's the little toe. So this is the posterior lateral approach. The Achilles was here. The perineal tendons are over here. And through that approach, I was able to fix the lateral malleolus as well as the distal tibium. In this case, there's a second incision medially that we used, an intermedial incision to fix the medial malleolar fracture. Next case. Although I wrote case two, this is actually case one. This is actually case two. This is a 41-year-old male, suffered a trimalleolar fracture. And in this case, a Mason type one posterior malleolar fracture. This is his x-rays in the splint. You see the high, high fibular fracture. No medial malleolar fracture, if you notice here, but there is this small posterior fragment involving the posterior malleolus. But this appears to be stable posteriorly. The talus is well reduced within the mortise there. So in this case, I elected to fix the long fibular shaft fracture and do the instability posteriorly. I didn't want to fix posteriorly. I went and used a flexible device, the Arthrex tight rope device. This is his initial post-op x-ray. And in the lateral, you can see these small shell fractures of the posterior malleolus. The next case is a 64-year-old female with osteoporotic bone, clear posterior instability, and again, a Mason type 2A fracture. So a higher fibular fracture, a medial malleolar fracture, and posterior instability. This is the CT scan showing that more comminuted posterior fragment. However, this was not a 2B. This was still a 2A, I thought, as there was really no medial component. I wanted to show this intraoperative shot where you can see I'm using my dental pick, really pulling down on this osteoporotic bone to get that articular cartilage lined up again and get that PITFL anatomically aligned. My two screws reducing the dome nicely there, and then the higher plate to fix the fibula, and a single screw fixing the medial malleolar fracture. And in the office, this is our post x-ray. I think I got that pretty well aligned and certainly she's now stable posteriorly. Final case is a 55-year-old female with an isolated ankle injury. This seemed to be a more of a subtle bimalleolar or trimalleolar fracture. And in this case, I felt this was more of a Mason type III. So no obvious medial malleolar fracture. The radiologist kindly measured 3.8 millimeters for me. Don't know what that was referring to. You can see the posterior malleolar fracture. And this is one of those subtle things. Look right in here. There is more going on. So on that AP view, you see that triangular shadow. That's something that can easily be missed if you don't look closely. Now, if you look at your lateral x-rays, the joint's not lining up. That's the posterior malleolar fragment there. That's the rest of the distal tibia. So clearly there's a posterior malleolar fragment here. Go to the CT scan, and there it is, a much higher, longer triangular-shaped fracture of the posterior malleolus. This one, I'll show the lateral first, was treated with a posterior plate as well as screws fixing distally. In this case, due to the high extent of the fracture, elected to use the posterior distal tibial plate. And again, hard to see once the fibular plate is in place, but we have the joint lined up again. The talus is now stable posteriorly. So in conclusion, the trend is towards directly, not indirectly, but directly fixing any unstable posterior malleolar fracture with joint malreduction, and I think that key is instability. If it's unstable posteriorly, fix it posteriorly. The indication for open reduction and internal fixation is now truly based on the advent of three-dimensional CT scans. Most of these can be approached through the posterior lateral approach, but be familiar with the posterior medial and the medial posterior medial approach. And finally, after posterior malleolar fixation, the syndesmosis may no longer require fixation. You've fixed at least 42% of it through that posterior malleolar fragment fixation, and perhaps that's all that really needs to be done. So thank you once again to everybody inviting me to the talk. I'm happy to converse directly with anybody. I'm available from email, websites, Twitter, anywhere. Thanks so much.

posterior malleolus fractures

ankle fractures

individualized approach

diagnosing

surgical indications

fixation approaches