Posterior malleolar fractures of the ankle

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.