Current State of the Posterior Malleolus Osteosynthesis Concept in Patients with Ankle Fractures (Literature Review)
ARTICLE PDF (Українська)


posterior malleolus
ankle joint
trimalleolar fracture

How to Cite

Kucher, I., & Liabakh, A. (2021). Current State of the Posterior Malleolus Osteosynthesis Concept in Patients with Ankle Fractures (Literature Review). TERRA ORTHOPAEDICA, (4(111), 42-52.


Summary. The problem of posterior malleolus (PM) fractures osteosynthesis remains the subject of scientific debate, despite extensive experience in surgical treatment and a large number of biomechanical and clinical studies.

Objective: to analyze current literary concepts of surgical treatment of PM in patients with ankle fractures.

Results and Сonclusions. The available literature does not provide a complete understanding of the problem of surgical treatment of PM fractures. The current consensus suggests that restoring the anatomy of the articular surface of the tibial plateau and concomitant damage to the medial and lateral structures of the ankle joint, along with ensuring its stability, is the key to the successful treatment of РМ injuries. The lack of high-quality recommendations and a unified protocol for the choice of treatment tactics, as well as a sufficiently high percentage of unsatisfactory results determine the need to improve the existing principles of surgical treatment.
ARTICLE PDF (Українська)


Herring M, Yoon P. Surgical treatment of posterior malleolus fractures and posterior fixation. Tech Foot Ankle Surg. 2018 Sep;17(3):141-50. DOI: 10.1097/BTF.0000000000000207.

Pflüger P, Braun K-F, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev. 2021 Aug;6(8):692-703. DOI: 10.1302/2058-5241.6.200138.

Larsen P, Rathleff MS, Elsoe R. Surgical versus conservative treatment for ankle fractures in adults - a systematic review and meta-analysis of the benefits and harms. Foot Ankle Surg. 2019 Aug;25(4):409-17. DOI: 10.1016/j.fas.2018.02.009.

Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg. 2021 Apr 9. DOI: 10.1007/s00402-021-03875-3.

Evers J, Barz L, Wähnert D, Grüneweller N, Raschke MJ, Ochman S. Size matters: the influence of the posterior fragment on patient outcomes in trimalleolar ankle fractures. Injury. 2015 Oct;46:S109-13. DOI: 10.1016/S0020-1383(15)30028-0.

Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures. Foot Ankle Clin. 2017 Mar;22(1):125-45. DOI: 10.1016/j.fcl.2016.09.009.

Rammelt S, Bartoníček J. Posterior malleolar fractures. JBJS Rev. 2020 Aug;8(8):e19.00207-e19.00207. DOI: 10.2106/JBJS.RVW.19.00207.

Tenenbaum S, Shazar N, Bruck N, Bariteau J. Posterior malleolus fractures. Orthop Clin North Am. 2017 Jan;48(1):81-9. DOI: 10.1016/j.ocl.2016.08.004.

Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg. 2015 Dec 8;41(6):587-600. DOI: 10.1007/s00068-015-0560-6.

White TO. In defence of the posterior malleolus. Bone Joint J. 2018 May;100-B(5):566-9. DOI: 10.1302/0301-620X.100B5.BJJ-2017-1440.R1.

van den Bekerom MPJ, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009 Jan;66(1):279-84. DOI: 10.1097/TA.0b013e318187eb16.

Verhage SM, Krijnen P, Schipper IB, Hoogendoorn JM. Persistent postoperative step-off of the posterior malleolus leads to higher incidence of post-traumatic osteoarthritis in trimalleolar fractures. Arch Orthop Trauma Surg. 2019 Mar 14;139(3):323-9. DOI: 10.1007/s00402-018-3056-0.

Zhou Q, Lu H, Wang Z, Yu S, Zhang H. Posterolateral approach with buttress plates and cannulated screw fixation for large posterior malleolus fractures. J Foot Ankle Surg. 2017 Nov;56(6):1173-9. DOI: 10.1053/j.jfas.2017.05.028.

Testa G, Ganci M, Amico M, Papotto G, Giardina SMC, Sessa G, et al. Negative prognostic factors in surgical treatment for trimalleolar fractures. Eur J Orthop Surg Traumatol. 2019 Aug 9;29(6):1325-30. DOI: 10.1007/s00590-019-02430-6.

Warner SJ, Schottel PC, Hinds RM, Helfet DL, Lorich DG. Fracture-dislocations demonstrate poorer postoperative functional outcomes among pronation external rotation IV ankle fractures. Foot Ankle Int. 2015 Jun 17;36(6):641-7. DOI: 10.1177/1071100715572222.

Blom RP, Meijer DT, de Muinck Keizer R-JO, Stufkens SAS, Sierevelt IN, Schepers T, et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury. 2019 Jul;50(7):1392-7. DOI: 10.1016/j.injury.2019.06.003.

Ebraheim NA, Mekhail AO, Haman SP. External rotation-lateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int. 1999 Jun 17;20(6):379-83. DOI: 10.1177/107110079902000607.

Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg. 2013 Jan 1;21(1):32-40. DOI: 10.5435/JAAOS-21-01-32.

Vacas-Sánchez E, Olaya-González C, Abarquero-Diezhandino A, Sánchez-Morata E, Vilá-Rico J. How to address the posterior malleolus in ankle fractures? A decision-making model based on the computerised tomography findings. Int Orthop. 2020 Jun 4;44(6):1177-85. DOI: 10.1007/s00264-020-04481-5.

Meijer DT, Doornberg JN, Sierevelt IN, Mallee WH, van Dijk CN, Kerkhoffs GM, et al. Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 2015 Oct;46(10):2024-9. DOI: 10.1016/j.injury.2015.07.019.

Solan MC, Sakellariou A. Posterior malleolus fractures. Bone Joint J. 2017 Nov;99-B(11):1413-9. DOI: 10.1302/0301-620X.99B11.BJJ-2017-1072.

Donohoe S, Alluri RK, Hill JR, Fleming M, Tan E, Marecek G. Impact of computed tomography on operative planning for ankle fractures involving the posterior malleolus. Foot Ankle Int. 2017 Dec 28;38(12):1337-42. DOI: 10.1177/1071100717731568.

Tarallo L, Micheloni GM, Mazzi M, Rebeccato A, Novi M, Catani F. Advantages of preoperative planning using computed tomography scan for treatment of malleolar ankle fractures. World J Orthop. 2021 Mar 18;12(3):129-39. DOI: 10.5312/wjo.v12.i3.129.

Zhang K, Jia X, Qiang M, Chen S, Wang S, Wang D, et al. Quantitative evaluation of articular involvement of posterior malleolus associated with operative indication: a comparative study of six methods based on radiography and CT. Biomed Res Int. 2020 Jan 8;2020:1-9. DOI: 10.1155/2020/6745626.

Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006 May;88(5):1085-92. DOI:10.2106/JBJS.E.00856.

Mason LW, Marlow WJ, Widnall J, Molloy AP. Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int. 2017 Nov 31;38(11):1229-35. DOI: 10.1177/1071100717719533.

Bartoníček J, Rammelt S, Kostlivý K, Vaněček V, Klika D, Trešl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015 Apr 24;135(4):505-16. DOI: 10.1007/s00402-015-2171-4.

Zhong S, Shen L, Zhao J, Chen J, Xie J, Shi Q, et al. Comparison of posteromedial versus posterolateral approach for posterior malleolus fixation in trimalleolar ankle fractures. Orthop Surg. 2017 Feb;9(1):69-76. DOI: 10.1111/os.12308.

Bulut T, Gursoy M, Ertem H. Fully threaded headless compression screw versus partially threaded cancellous lag screw in medial malleolus fractures: clinical and radiological outcomes. Eur J Trauma Emerg Surg. 2021 Feb 27;47(1):179-85. DOI: 10.1007/s00068-019-01207-0.

Peng J, McKissack H, Yu J, He JK, Montgomery T, Moraes L, et al. Anatomic structures at risk in anteroposterior screw fixation of posterior malleolar fractures: a cadaver study. Foot Ankle Surg. 2021 Feb;27(2):162-7. DOI: 10.1016/j.fas.2020.03.010.

Patel A, Charles L, Ritchie J. A complication of posterior malleolar fracture fixation. J Foot Ankle Surg. 2016 Mar;55(2):383-6. DOI: 10.1053/j.jfas.2014.12.040.

Bennett C, Behn A, Daoud A, Nork S, Sangeorzan B, Dikos G, et al. Buttress plating versus anterior-to-posterior lag screws for fixation of the posterior malleolus: a biomechanical study. J Orthop Trauma. 2016 Dec;30(12):664-9. DOI: 10.1097/BOT.0000000000000699.

Clarke T, Whitworth N, Platt S. Defining a safe zone for percutaneous screw fixation of posterior malleolar fractures. J Foot Ankle Surg. 2021 Sep;60(5):929-34. DOI: 10.1053/j.jfas.2020.10.013.

Williams C, Momenzadeh K, Michalski M, Kwon JY, Nazarian A, Miller CP. Anatomic and radiographic safe zone for posterior malleolar screw placement. Foot Ankle Int. 2021 Dec 1;42(12):1598-605. DOI: 10.1177/10711007211022747.

Palmanovich E, Ohana N, Yaacobi E, Segal D, Iftach H, Sharfman ZT, et al. Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs. J Orthop Surg Res. 2020 Dec 26;15(1):119. DOI: 10.1186/s13018-020-01637-2.

Kimball JS, Ruckle DE, Rajfer RA, Johnson JP. Anatomic analysis of a percutaneous fixation technique for the posterior malleolus using posterior-to-anterior-directed cannulated screws: a cadaveric study and technique description. J Am Acad Orthop Surg Glob Res Rev. 2021 Feb;5(2). DOI: 10.5435/JAAOSGlobal-D-20-00215.

Gonzalez TA, Watkins C, Drummond R, Wolf JC, Toomey EP, DiGiovanni CW. Transfibular approach to posterior malleolus fracture fixation. Foot Ankle Int. 2016 Apr 23;37(4):440-5. DOI: 10.1177/1071100715617760.

von Rüden C, Hackl S, Woltmann A, Friederichs J, Bühren V, Hierholzer C. Der posterolaterale zugang - eine alternative zur geschlossenen anterior-posterioren schraubenosteosynthese bei komplexen sprunggelenkfrakturen. Z Orthop Unfall. 2015 May 6;153(03):289-95. DOI: 10.1055/s-0035-1545706.

Vidović D, Elabjer E, Muškardin I v. a., Milosevic M, Bekic M, Bakota B. Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation. Injury. 2017 Nov;48:S65-9. DOI: 10.1016/S0020-1383(17)30743-X.

O’Connor TJ, Mueller B, Ly T v., Jacobson AR, Nelson ER, Cole PA. “A to P” screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015 Apr;29(4):e151-6. DOI: 10.1097/BOT.0000000000000230.

Gandham S, Millward G, Molloy AP, Mason LW. Posterior malleolar fractures: a CT guided incision analysis. Foot (Edinb). 2020 Jun;43:101662. DOI: 10.1016/j.foot.2019.101662.

Hoogendoorn JM. Posterior malleolar open reduction and internal fixation through a posterolateral approach for trimalleolar fractures. JBJS Essent Surg Tech. 2017 Oct 25;7(4):e31. DOI:10.2106/JBJS.ST.17.00016.

Sultan F, Zheng X, Pan Z, Zheng Q, Li H, Wang J. Characteristics of intercalary fragment in posterior malleolus fractures. Foot Ankle Surg. 2020 Apr;26(3):289-94. DOI: 10.1016/j.fas.2019.03.011.

Zbeda RM, Friedel SP, Katchis SD, Weiner L. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach. Orthopedics. 2020 May;43(3). DOI: 10.3928/01477447-20200213-01.

Bali N, Aktselis I, Ramasamy A, Mitchell S, Fenton P. An evolution in the management of fractures of the ankle. Bone Joint J. 2017 Nov;99-B(11):1496-501. DOI: 10.1302/0301-620X.99B11.BJJ-2017-0558.R1.

He W, Yang Y, Zhou H, Xia J, Li B, Yu T. Combined posteromedial and posterolateral approaches for 2-part posterior malleolar fracture fixation. Foot Ankle Int. 2020 Oct 18;41(10):1234-9. DOI: 10.1177/1071100720937637.

Choi JY, Kim JH, Ko HT, Suh JS. Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture. J Foot Ankle Surg. 2015 Jul;54(4):559-64. DOI: 10.1053/j.jfas.2014.09.043.

Xing W, Wang Y, Sun L, Wang L, Kong Z, Zhang C, et al. Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis. Medicine (Baltimore). 2018 Sep;97(37):e12079. DOI: 10.1097/MD.0000000000012079.

Xing W, Xie P, Wang L, Liu C, Cui J, Zhang Z, et al. The application of intraoperative ankle dislocation approach in the treatment of the unstable trimalleolar fractures involving posterior ankle comminuted fracture: a retrospective cohort study. BMC Surg. 2018 Dec 18;18(1):23. DOI: 10.1186/s12893-018-0356-9.

Duan X, Kadakia AR. Operative treatment of posterior malleolar fractures. Open Orthop J. 2017 Jul 31;11(1):732-42. DOI: 10.2174/1874325001711010732.

Mertens M, Wouters J, Kloos J, Nijs S, Hoekstra H. Functional outcome and general health status after plate osteosynthesis of posterior malleolus fractures – the quest for eligibility. Injury. 2020 Apr;51(4):1118-24. DOI: 10.1016/j.injury.2020.02.109.

Jeyaseelan L, Bua N, Parker L, Sohrabi C, Trockels A, Vris A, et al. Outcomes of posterior malleolar fixation in ankle fractures in a major trauma centre. Injury. 2021 Apr;52(4):1023-7. DOI: 10.1016/j.injury.2020.12.006.

Li M, Collier RC, Hill BW, Slinkard N, Ly T. Comparing different surgical techniques for addressing the posterior malleolus in supination external rotation ankle fractures and the need for syndesmotic screw fixation. J Foot Ankle Surg. 2017 Jul;56(4):730-4. DOI: 10.1053/j.jfas.2017.01.053.

Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010 Apr;468(4):1129-35. DOI: 10.1007/s11999-009-1111-4.

Behery OA, Narayanan R, Konda SR, Tejwani NC, Egol KA. Posterior malleolar fixation reduces the incidence of trans-syndesmotic fixation in rotational ankle fracture repair. Iowa Orthop J. 41(1):121-5. PMID: 34552413.

Stringfellow TD, Walters ST, Nash W, Ahluwalia R. Management of posterior malleolus fractures: a multicentre cohort study in the United Kingdom. Foot Ankle Surg. 2021 Aug;27(6):629-35. DOI: 10.1016/j.fas.2020.08.003.

Marques Ribeiro H, Silva J, Teixeira R, Fernandes P, Sobral L, Rosa I. Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis. Injury. 2021 Mar;52(3):633-7. DOI: 10.1016/j.injury.2020.10.021.

Evers J, Fischer M, Raschke M, Riesenbeck O, Milstrey A, Gehweiler D, et al. Leave it or fix it? How fixation of a small posterior malleolar fragment neutralizes rotational forces in trimalleolar fractures. Arch Orthop Trauma Surg. 2021 Jan 28; DOI: 10.1007/s00402-021-03772-9.

Baumbach SF, Herterich V, Damblemont A, Hieber F, Böcker W, Polzer H. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury. 2019 Feb;50(2):564-70. DOI: 10.1016/j.injury.2018.12.025.

Odak S, Ahluwalia R, Unnikrishnan P, Hennessy M, Platt S. Management of posterior malleolar fractures: a systematic review. J Foot Ankle Surg. 2016 Jan;55(1):140-5. DOI: 10.1053/j.jfas.2015.04.001.

Warner SJ, Garner MR, Schottel PC, Hinds RM, Loftus ML, Lorich DG. Analysis of PITFL injuries in rotationally unstable ankle fractures. Foot Ankle Int. 2015 Apr 3;36(4):377-82. DOI: 10.1177/1071100714558845.

Levack AE, Warner SJ, Gausden EB, Helfet DL, Lorich DG. Comparing functional outcomes after injury-specific fixation of posterior malleolar fractures and equivalent ligamentous injuries in rotational ankle fractures. J Orthop Trauma. 2018 Apr;32(4):e123-8. DOI: 10.1097/BOT.0000000000001104.

Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994 Oct;10(5):558-60. DOI: 10.1016/S0749-8063(05)80014-3.

Raasch WG, Larkin JJ, Draganich LF. Assessment of the posterior malleolus as a restraint to posterior subluxation of the ankle. J Bone Joint Surg Am. 1992 Sep;74(8):1201-6. PMID: 1400549.

Zhan Y, Yan X, Xia R, Cheng T, Luo C. Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: a prospective and comparative study. Injury. 2016 Jul;47(7):1574-80. DOI: 10.1016/j.injury.2016.04.014.

Myers DM, Pulido SH, Forsting S, Umbel B, Taylor BC. Effect of early weight bearing on outcomes after open reduction and internal fixation of trimalleolar ankle fractures. Orthopedics. 2021 May;44(3):160-5. DOI: 10.3928/01477447-20210104-04.

Rammelt S, Bartoníček J, Neumann AP, Kroker L. Frakturen der lateralen tibiavorderkante. Unfallchirurg. 2021 Mar 12;124(3):212-21. DOI: 10.1007/s00113-021-00959-y.

Rammelt S, Bartoníček J, Schepers T, Kroker L. Fixation of anterolateral distal tibial fractures: the anterior malleolus. Oper Orthop Traumatol. 2021 Apr 22;33(2):125-38. DOI: 10.1007/s00064-021-00703-0.

Franzone JM, Vosseller JT. Posterolateral approach for open reduction and internal fixation of a posterior malleolus fracture—hinging on an intact PITFL to disimpact the tibial plafond. Foot Ankle Int. 2013 Aug 12;34(8):1177-81. DOI: 10.1177/1071100713481455.

Nasrallah K, Einal B, Shtarker H. Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair? Orthop Rev (Pavia). 2021 Mar 30;13(1). DOI: 10.4081/or.2021.8784.

Baumbach SF, Böcker W, Polzer H. Offene reposition und interne fixation von frakturen des posterioren malleolus. Oper Orthop Traumatol. 2021 Apr 25;33(2):112-24. DOI: 10.1007/s00064-021-00705-y.

Firoozabadi R, Harnden E, Krieg JC. Immediate weight-bearing after ankle fracture fixation. Adv Orthop. 2015;2015:1-6. DOI: 10.1155/2015/491976.

Papachristou G, Efstathopoulos N, Levidiotis C, Chronopoulos E. Early weight bearing after posterior malleolar fractures: an experimental and prospective clinical study. J Foot Ankle Surg. 2003 Mar;42(2):99-104. DOI: 10.1016/S1067-2516(03)70009-X.

Swart E, Bezhani H, Greisberg J, Vosseller JT. How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members. Injury. 2015 Jun;46(6):1127-30. DOI: 10.1016/j.injury.2015.03.029.

Veltman ES, Halma JJ, de Gast A. Longterm outcome of 886 posterior malleolar fractures: a systematic review of the literature. Foot Ankle Surg. 2016 Jun;22(2):73-7. DOI: 10.1016/j.fas.2015.05.003.

Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg. 2018 Sep 12;138(9):1213-22. DOI: 10.1007/s00402-018-2949-2.

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.