Fractures of the Peroneal Malleolus: Current Concepts
Journal: Advances in Medicine and Engineering Interdisciplinary Research DOI: 10.32629/ameir.v2i3.2624
Abstract
Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilizing the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.
Keywords
ankle fractures; fibula fractures; associated injuries; fibular fixation options; decision-making algorithm
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[2] Rydberg EM, Wennergren D, Stigevall C, Ekelund J, Möller M. Epidemiology of more than 50,000 ankle fractures in the Swedish Fracture Register during a period of 10 years. J Orthop Surg Res. 2023;18:79.
[3] Pearce O, Al-Hourani K, Kelly M. Ankle fractures in the elderly: Current concepts. Injury. 2020;51:2740 - 7.
[4] Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? Bone Joint J. 2017;99 - B:851 - 5.
[5] Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures. EFORT Open Rev. 2018;3:294 - 303.
[6] Boluda-Mengod J, Munoz-Ortus R, Rendón-Díaz D, Ramírez de Paz R, Pais-Brito JL, Herrera-Pérez M. Fracturas osteoporóticas de tobillo: conceptos actuales. Revista del Pie y Tobillo. 2018;32:71 - 80.
[7] Stockwell E, Thomas P, Grossman L, Lyden E, Mormino M, Siebler J, et al. Successful outcomes with nonoperative treatment and immediate weightbearing despite stress-positive radiographs in isolated distal fibula (OTA/AO 44B) fractures. J Orthop Trauma. 2024;38:E20 - 7.
[8] Schnetzke M, Vetter SY, Beisemann N, Swartman B, Grützner PA, Franke J. Management of syndesmotic injuries: What is the evidence? World J Orthop. 2016;7:718.
[9] Spindler FT, Böcker W, Polzer H, Baumbach SF. A systematic review of studies on the diagnostics and classification system used in surgically treated, acute, isolated, unstable syndesmotic injury: a plea for uniform definition of syndesmotic injuries. EFORT Open Rev. 2024;9:16 - 24.
[10] Bartonícek J, Rammelt S, Tuˇcek M. Maisonneuve fractures of the ankle: A critical analysis review. JBJS Rev. 2022;10.
[11] Varenne Y, Curado J, Asloum Y, Salle de Chou E, Colin F, Gouin F. Analysis of risk factors of the postoperative complications of surgical treatment of ankle fractures in the elderly: A series of 477 patients. Orthop Traumatol Surg Res. 2016;102:S245 - 8.
[12] SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009;91:1042 - 9.
[13] Lanzetti RM, Lupariello D, Venditto T, Guzzini M, Ponzo A, De Carli A, et al. The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures. Diabetes Metab Res Rev. 2018;34:e2954.
[14] Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32:S1 - 170.
[15] Olczak J, Emilson F, Razavian A, Antonsson T, Stark A, Gordon M. Ankle fracture classification using deep learning: Automating detailed AO Foundation/Orthopedic Trauma Association (AO/OTA) 2018 malleolar fracture identification reaches a high degree of correct classification. Acta Orthop. 2020;92:102 - 8.
[16] Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957 - 85.
[17] Warner SJ, Garner MR, Hinds RM, Helfet DL, Lorich DG. Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures. J Orthop Trauma. 2015;29:574 - 8.
[18] Haller JM, Ross H, Jacobson K, Ou Z, Rothberg D, Githens M. Supination adduction ankle fractures: Ankle fracture or pilon variant? Injury. 2020;51:759 - 63.
[19] Ma Z, Zhan J, Zhu N, Zheng L, Hu Y, Liu W, et al. A comparative study of the clinical efficacy of supination-adduction type II ankle fracture surgery based on the medial pilon fracture concept versus the ankle fracture concept. BMC Musculoskelet Disord. 2021;22:936.
[20] Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, et al. Fibula fractures management. World J Orthop. 2021;12:254 - 69.
[21] Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: Investigation and treatment options. Dtsch Arztebl Int. 2014;111:377 - 88.
[22] Vega J, Malagelada F, Manzanares Céspedes MC, Dalmau-Pastor M. The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surg Sports Traumatol Arthrosc. 2020;28:8 - 17.
[23] Haraguchi N, Toga H, Shiba N, Kato F. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury. Am J Sports Med. 2007;35:1144 - 52.
[24] Githens MF, DeBaun MR, Jacobsen KA, Ross H, Firoozabadi R, Haller J. Plafond malreduction and talar dome impaction accelerates arthrosis after supination-adduction ankle fracture. Foot Ankle Int. 2021;42:1245 - 53.
[25] Luo B, Wang Y, Wang D. Effect of buttress plate in Herscovici type D vertical medial malleolar fractures and peripheral fractures: A retrospective comparative cohort study. J Orthop Surg Res. 2023;18:411.
[26] Holmes JR, Acker WB, Murphy JM, McKinney A, Kadakia AR, Irwin TA. A novel algorithm for isolated Weber B ankle fractures: A retrospective review of 51 nonsurgically treated patients. J Am Acad Orthop Surg. 2016;24:645 - 52.
[27] Stufkens SAS, van den Bekerom MPJ, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination - external rotation ankle fractures: A review. Strategies Trauma Limb Reconstr. 2012;7:73 - 85.
[28] De Krom MA, Kalmet PH, Jagtenberg EM, Hermus JP, van Vugt R, Seelen HA, et al. Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis. Injury. 2022;53:724 - 31.
[29] Yu T, Zhang Y, Zhou H, Yang Y. Distribution of posterior malleolus fracture lines in ankle fracture of supination-external rotation. Orthop Traumatol Surg Res. 2021;107:103000.
[30] Gregersen MG, Fagerhaug Dalen A, Nilsen F, Molund M. The anatomy and function of the individual bands of the deltoid ligament - and implications for stability assessment of SER ankle fractures. Foot Ankle Orthop. 2022;7.
[31] Chun DI, Kim J, Kim YS, Cho JH, Won SH, Park SY, et al. Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures. Injury. 2019;50:1382 - 7.
[32] Tansey PJ, Chen J, Panchbhavi VK. Current concepts in ankle fractures. J Clin Orthop Trauma. 2023;45:102260.
[33] Seidel A, Krause F, Weber M. Weightbearing vs gravity stress radiographs for stability evaluation of supination-external rotation fractures of the ankle. Foot Ankle Int. 2017;38: 736 - 44.
[34] Bartonícek J, Rammelt S, Kostlivy K, Vanecek V, Klika D, Tresl I. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135:505 - 16.
[35] Rammelt S, Boszczyk A. Computed tomography in the diagnosis and treatment of ankle fractures. JBJS Rev. 2018;6:e7.
[36] Rydberg EM, Skoglund J, Brezicka H, Ekelund J, Sundfeldt M, Möller M, et al. Fractures of the lateral malleolus - a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm. BMC Musculoskelet Disord. 2022;23:401.
[37] Fernández-Rojas E, Herrera-Pérez M, Vilá-Rico J. Fracturas de maléolo posterior: indicaciones de fijación y vías de abordaje. Rev Esp Cir Ortop Traumatol. 2023;67:160 - 9.
[38] McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, et al. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop. 2022;13:969 - 77.
[39] Williams BT, Ahrberg AB, Goldsmith MT, Campbell KJ, Shirley L, Wijdicks CA, et al. Ankle syndesmosis. Am J Sports Med. 2015;43:88 - 97.
[40] Edwards GS, DeLee JC. Ankle diastasis without fracture. Foot Ankle. 1984;4:305 - 12.
[41] Hallbauer J, Schenk P, Herrmann L, Ullrich BW, Biedermann U, Wildemann B, et al. Objective assessment of syndesmosis stability using the Hook test. J Clin Med. 2023;12:4580.
[42] Regauer M, Mackay G, Nelson O, Böcker W, Ehrnthaller C. Evidence-based surgical treatment algorithm for unstable syndesmotic injuries. J Clin Med. 2022;11:331.
[43] Chun D-I, Cho J-H, Min T- H, Park SY, Kim K-H, Kim J-H, et al. Diagnostic accuracy of radiologic methods for ankle syndesmosis injury: A systematic review and meta-analysis. J Clin Med. 2019;8:968.
[44] Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165 - 71.
[45] Patel R, McCarthy K, Christensen J, Jacobs B, Karsch J, Sephien A, et al. Cost analysis and clinical outcomes of anatomic precontoured locking versus conventional plates for distal fibula ankle fractures. Eur J Orthop Surg Traumatol. 2024;34:959 - 65.
[46] Ahn JH, Cho SH, Jeong M, Kim YC. One-third tubular plate remains a clinically good option in Danis-Weber type b distal fibular fracture fixation. Orthop Surg. 2021;13:2301 - 9.
[47] Dhillon MS, Rajnish RK, Kumar P, Sharma S, Singh GP, Srivastava A. A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: A systematic review and meta-analysis. Eur J Orthop Surg Traumatol. 2024;34:75 - 89.
[48] Huang Z, Liu L, Tu C, Zhang H, Fang Y, Yang T, et al. Comparison of three plate system for lateral malleolar fixation. BMC Musculoskelet Disord. 2014;15:360.
[49] Minihane KP, Lee C, Ahn C, Zhang LQ, Merk BR. Comparison of lateral locking plate and antiglide plate for fixation of distal fibular fractures in osteoporotic bone: A biomechanical study. J Orthop Trauma. 2006;20:562 - 6.
[50] Bilgetekin YG, Catma MF, Öztürk A, Ünlü S, Ersan Ö. Comparison of different locking plate fixation methods in lateral malleolus fractures. Foot Ankle Surg. 2019;25:366 - 70.
[51] Eckel TT, Glisson RR, Anand P, Parekh SG. Biomechanical comparison of 4 different lateral plate constructs for distal fibula fracture. Foot Ankle Int. 2013;34:1588 - 95.
[52] Herrera-Pérez M, Gutiérrez-Morales MJ, Guerra-Ferraz A, Pais-Brito JL, Boluda-Mengod J, Garcés GL. Locking versus nonlocking one-third tubular plates for treating osteoporotic distal fibula fractures: a comparative study. Injury. 2017;48:S60 - 5.
[53] Schaffer JJ, Manoli A. The antiglide plate for distal fibular fixation. A biomechanical comparison with fixation with a lateral plate. J Bone Joint Surg Am. 1987;69:596 - 604.
[54] Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: The effect of plate and screw position. Foot Ankle Int. 2005;26:281 - 5.
[55] Kilian M, Csörgö P, Vajczikova S, Luha J, Zamborsky R. Antiglide versus lateral plate fixation for Danis-Weber type B malleolar fractures caused by supination-external rotation injury. J Clin Orthop Trauma. 2017;8:327 - 31.
[56] McKean J, Cuellar DO, Hak D, Mauffrey C. Osteoporotic ankle fractures: An approach to operative management. Orthopedics. 2013;36:936 - 40.
[57] Kwaadu KY, Fleming JJ, Lin D. Management of complex fibular fractures: Double plating of fibular fractures. J Foot Ankle Surg. 2015;54:288 - 94.
[58] Vance DD, Vosseller JT. Double plating of distal fibula fractures. Foot Ankle Spec. 2017;10:543 - 6.
[59] Liu JH, Zhang Q, Wei GH, Liu L, Mu X, Li ML, et al. A retrospective comparison of double-hooked locking plates versus non-locking plates in minimally invasive percutaneous plate osteosynthesis for the treatment of comminuted distal fibular fractures accompanied by tibial Pilon fractures. J Orthop Surg Res. 2023;18.
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