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Malleolus Fracture
Corrie M. Yablon, MD; Julia R. Crim, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Definitions

                • Fractures (fxs) of distal tibia and fibula are divided into
                  • Pilon fx: tibial plafond fx due to axial load
                    • May secondarily involve malleoli
                  • Malleolus fx: due to shear or twisting forces
                • Maisonneuve fx: fx of proximal fibula due to pronation-external rotation (PER) injury of ankle
                  • Reflects injury to tibiofibular syndesmosis and interosseous membrane
                  • Associated with medial malleolus (MM) fx or deltoid ligament injury, and posterior malleolus (PM) fx
                • Pott or Dupuytren fx (obsolete): fx of distal fibula above syndesmosis
                • Earle (Volkmann) fx: fx of lateral margin of PM
                  • Due to avulsion of posterior inferior tibiofibular ligament (PITFL)
                • Chaput-Tillaux fx: fx of lateral margin of anterior tibia
                  • Due to avulsion of anterior inferior tibiofibular ligament (AITFL)

              IMAGING

              • General Features

                • Radiographic Findings

                  • CT Findings

                    • MR Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Staging, Grading, & Classification

                              • Relevant Anatomy

                                CLINICAL ISSUES

                                • Presentation

                                  • Natural History & Prognosis

                                    • Treatment

                                      • Common Complications

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          • Image Interpretation Pearls

                                            • Reporting Tips

                                              Selected References

                                              1. Pina G et al: Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return. Arch Orthop Trauma Surg. 141(1):99-104, 2021
                                              2. He JQ et al: Pathoanatomy and injury mechanism of typical Maisonneuve fracture. Orthop Surg. 12(6):1644-51, 2020
                                              3. Stringfellow TD et al: Management of posterior malleolus fractures: a multicentre cohort study in the United Kingdom. Foot Ankle Surg. Epub, 2020
                                              4. Carter TH et al: Medial malleolar fractures: current treatment concepts. Bone Joint J. 101-B(5):512-21, 2019
                                              5. Mason LW et al: Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int. 38(11):1229-35, 2017
                                              6. Veltman ES et al: Longterm outcome of 886 posterior malleolar fractures: a systematic review of the literature. Foot Ankle Surg. 22(2):73-7, 2016
                                              7. Droog R et al: Incidence and clinical relevance of tibiofibular synostosis in fractures of the ankle which have been treated surgically. Bone Joint J. 97-B(7):945-9, 2015
                                              8. Gardner MJ et al: Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg. 23(8):510-8, 2015
                                              9. Meijer DT et al: Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 46(10):2024-9, 2015
                                              10. Crim J et al: CT assessment of the prevalence of retinacular injuries associated with hindfoot fractures. Skeletal Radiol. 42(4):487-92, 2013
                                              11. Russo A et al: Ankle fracture: radiographic approach according to the Lauge-Hansen classification. Musculoskelet Surg. 97 Suppl 2:S155-60, 2013
                                              12. Lempainen L et al: Medial malleolar stress fracture in athletes: diagnosis and operative treatment. Scand J Surg. 101(4):261-4, 2012
                                              13. Sanders DW et al: Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial. J Orthop Trauma. 26(3):129-34, 2012
                                              14. Gougoulias N et al: Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res. 468(1):243-51, 2010
                                              15. Miller AN et al: Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 468(4):1129-35, 2010
                                              16. van den Bekerom MP et al: Is fibular fracture displacement consistent with tibiotalar displacement? Clin Orthop Relat Res. 468(4):969-74, 2010
                                              17. Büchler L et al: Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma. 23(3):208-12, 2009
                                              18. Stufkens SA et al: Long-term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg Br. 91(12):1607-11, 2009
                                              19. Jowett AJ et al: Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 29(7):716-21, 2008
                                              20. Stark E et al: Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma. 21(9):643-6, 2007
                                              21. Shariff SS et al: Lauge-Hansen classification--a literature review. Injury. 37(9):888-90, 2006
                                              22. Mulligan ME: Ankle and foot trauma. Semin Musculoskelet Radiol. ;4(2):241-53, 2000
                                              23. Brage ME et al: Ankle fracture classification: a comparison of reliability of three x-ray views versus two. Foot Ankle Int. 19(8):555-62, 1998
                                              24. Kennedy JG et al: An evaluation of the Weber classification of ankle fractures. Injury. 29(8):577-80, 1998
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        • Diagnostic Checklist

                                                          TERMINOLOGY

                                                          • Definitions

                                                            • Fractures (fxs) of distal tibia and fibula are divided into
                                                              • Pilon fx: tibial plafond fx due to axial load
                                                                • May secondarily involve malleoli
                                                              • Malleolus fx: due to shear or twisting forces
                                                            • Maisonneuve fx: fx of proximal fibula due to pronation-external rotation (PER) injury of ankle
                                                              • Reflects injury to tibiofibular syndesmosis and interosseous membrane
                                                              • Associated with medial malleolus (MM) fx or deltoid ligament injury, and posterior malleolus (PM) fx
                                                            • Pott or Dupuytren fx (obsolete): fx of distal fibula above syndesmosis
                                                            • Earle (Volkmann) fx: fx of lateral margin of PM
                                                              • Due to avulsion of posterior inferior tibiofibular ligament (PITFL)
                                                            • Chaput-Tillaux fx: fx of lateral margin of anterior tibia
                                                              • Due to avulsion of anterior inferior tibiofibular ligament (AITFL)

                                                          IMAGING

                                                          • General Features

                                                            • Radiographic Findings

                                                              • CT Findings

                                                                • MR Findings

                                                                  • Imaging Recommendations

                                                                    DIFFERENTIAL DIAGNOSIS

                                                                      PATHOLOGY

                                                                      • General Features

                                                                        • Staging, Grading, & Classification

                                                                          • Relevant Anatomy

                                                                            CLINICAL ISSUES

                                                                            • Presentation

                                                                              • Natural History & Prognosis

                                                                                • Treatment

                                                                                  • Common Complications

                                                                                    DIAGNOSTIC CHECKLIST

                                                                                    • Consider

                                                                                      • Image Interpretation Pearls

                                                                                        • Reporting Tips

                                                                                          Selected References

                                                                                          1. Pina G et al: Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return. Arch Orthop Trauma Surg. 141(1):99-104, 2021
                                                                                          2. He JQ et al: Pathoanatomy and injury mechanism of typical Maisonneuve fracture. Orthop Surg. 12(6):1644-51, 2020
                                                                                          3. Stringfellow TD et al: Management of posterior malleolus fractures: a multicentre cohort study in the United Kingdom. Foot Ankle Surg. Epub, 2020
                                                                                          4. Carter TH et al: Medial malleolar fractures: current treatment concepts. Bone Joint J. 101-B(5):512-21, 2019
                                                                                          5. Mason LW et al: Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int. 38(11):1229-35, 2017
                                                                                          6. Veltman ES et al: Longterm outcome of 886 posterior malleolar fractures: a systematic review of the literature. Foot Ankle Surg. 22(2):73-7, 2016
                                                                                          7. Droog R et al: Incidence and clinical relevance of tibiofibular synostosis in fractures of the ankle which have been treated surgically. Bone Joint J. 97-B(7):945-9, 2015
                                                                                          8. Gardner MJ et al: Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg. 23(8):510-8, 2015
                                                                                          9. Meijer DT et al: Guesstimation of posterior malleolar fractures on lateral plain radiographs. Injury. 46(10):2024-9, 2015
                                                                                          10. Crim J et al: CT assessment of the prevalence of retinacular injuries associated with hindfoot fractures. Skeletal Radiol. 42(4):487-92, 2013
                                                                                          11. Russo A et al: Ankle fracture: radiographic approach according to the Lauge-Hansen classification. Musculoskelet Surg. 97 Suppl 2:S155-60, 2013
                                                                                          12. Lempainen L et al: Medial malleolar stress fracture in athletes: diagnosis and operative treatment. Scand J Surg. 101(4):261-4, 2012
                                                                                          13. Sanders DW et al: Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial. J Orthop Trauma. 26(3):129-34, 2012
                                                                                          14. Gougoulias N et al: Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res. 468(1):243-51, 2010
                                                                                          15. Miller AN et al: Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 468(4):1129-35, 2010
                                                                                          16. van den Bekerom MP et al: Is fibular fracture displacement consistent with tibiotalar displacement? Clin Orthop Relat Res. 468(4):969-74, 2010
                                                                                          17. Büchler L et al: Reliability of radiologic assessment of the fracture anatomy at the posterior tibial plafond in malleolar fractures. J Orthop Trauma. 23(3):208-12, 2009
                                                                                          18. Stufkens SA et al: Long-term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg Br. 91(12):1607-11, 2009
                                                                                          19. Jowett AJ et al: Medial malleolar stress fracture secondary to chronic ankle impingement. Foot Ankle Int. 29(7):716-21, 2008
                                                                                          20. Stark E et al: Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma. 21(9):643-6, 2007
                                                                                          21. Shariff SS et al: Lauge-Hansen classification--a literature review. Injury. 37(9):888-90, 2006
                                                                                          22. Mulligan ME: Ankle and foot trauma. Semin Musculoskelet Radiol. ;4(2):241-53, 2000
                                                                                          23. Brage ME et al: Ankle fracture classification: a comparison of reliability of three x-ray views versus two. Foot Ankle Int. 19(8):555-62, 1998
                                                                                          24. Kennedy JG et al: An evaluation of the Weber classification of ankle fractures. Injury. 29(8):577-80, 1998