Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture, who underwent a CT. The Mason and Molloy posterior malleolus fracture classification system was used. Results. 764 diaphyseal tibial fractures were analysed, 300 had a CT. 127 were intra-articular fractures. 83 (27.7%) were classifiable using Mason and Molloy classification. There were 8 type 1 (9.6%), 43 type 2 (51.8%), 5 type 2B (6.0%) and 27 type 3 (32.5%). 90.4% (n=75) of the posterior malleolar fractures, were undisplaced. The majority of PM fractures occurred in type 42A1 (65 of 142 tibia fractures) and 42B1 (11 of 16). Conclusions. Most PM fractures occurred after a rotational mechanism. Unlike, the PM fractures of the ankle, the majority of PM fractures associated with tibia fractures are undisplaced. We theorise that unlike the force transmission in ankle fractures where the rotational force is in the axial plane in a distal-proximal direction, in the PM fractures related to fractures of the tibia, the rotational force in the axial plane progresses from proximal-distal. Therefore, the force transmission which exits posteriorly, finally dissipates the force and thus unlikely to displace

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Several studies demonstrate a high proportion of diaphyseal tibial fractures have ipsilateral occult posterior malleolus fractures, this ranges from 22–92.3%. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture and who underwent a CT. The articular fracture extension was categorised into either posterior malleolar (PM) or other fracture. Results. 764 fractures were analysed, 300 had a CT. There were 127 intra-articular fractures. 83 (65.4%) cases were PM and 44 were other fractures. On univariate analysis for PM fractures, fibular spiral (p=.016) fractures, no fibular fracture(p=.003), lateral direction of the tibial fracture (p=.04), female gender (p=.002), AO 42B1 (p=.033) and an increasing angle of tibial fracture. On multivariate regression analysis a high angle of tibia fracture was significant. Other fracture extensions were associated with no fibular fracture (p=.002), medial direction of tibia fracture (p=.004), female gender (p=.000), and AO 42A1 (p=.004), 42A2 (p=.029), 42B3 (p=.035) and 42C2 (p=.032). On multivariate analysis, the lateral direction of tibia fracture, and AO classification 42A1 and 42A2 were significant. Conclusions. Articular extension happened in 42.3%. A number of factors were associated with the extension, however multivariate analysis did not create a suitable prediction model. Nevertheless, rotational tibia fractures with a high angle of fracture should have further investigation with a CT

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Purpose. The aim of this prospective study was to determine the usefulness of a gravity stress view in detecting instability in isolated Weber B fractures of the fibula. Materials and methods. We used a standard protocol for patient selection, exclusion, surgery/conservative management and follow-up. Open fractures, fracture dislocations, those with medial/posterior malleolus fractures and those with preliminary X-rays showing a talar shift/tilt were excluded. If the medial clear space increased beyond 4mm on stress radiographs, surgical reduction and fixation of the lateral malleolus was performed. If this remained 4mm or less conservative treatment was undertaken. We followed these patients at 2, 4, 6 and 12 weekly intervals. Results. We recruited 18 patients with isolated Weber B fractures. In 7 patients the medial clear space increased from 4mm to an average of 6.29 mm (Range 5-7mm). 6 of these 7 patients were operated. The medial clear space remained 4mm or less in the remaining 11 patients and were therefore managed conservatively. No complications were noted in either the surgical or the non-surgical group. None of the conservatively managed fractures showed radiological features of instability on follow up. All the 17 patients who were followed up in our hospital had excellent final AOFAS Scores. Conclusion. We conclude that gravity stress views are useful in determining the stability of Weber B fractures of the ankle