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Tuček M, Bartoníček J, Fojtík P, Kamin K, Rammelt S. Injury to the posterior malleolus in Maisonneuve fractures. Eur J Trauma Emerg Surg 2024; 50:1007-1014. [PMID: 38041703 PMCID: PMC11249719 DOI: 10.1007/s00068-023-02394-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture. METHODS The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula. RESULTS A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients. CONCLUSION Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.
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Affiliation(s)
- Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic.
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic
| | - Petr Fojtík
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, U Vojenské Nemocnice 1200, Prague 6, 169 02, Czech Republic
| | - Konrad Kamin
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Tu DP, Cai LJ, Zhao HY, Huang LG, Nie J. Complicated Bosworth fracture-dislocation: A case report and review of the literature. Chin J Traumatol 2023; 26:344-350. [PMID: 37925272 PMCID: PMC10755783 DOI: 10.1016/j.cjtee.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/30/2023] [Accepted: 06/02/2023] [Indexed: 11/06/2023] Open
Abstract
Bosworth fracture and dislocation is relatively rare, accounting for about 1% of ankle fractures. It is characterized by the proximal fibula fracture embedded in the posterolateral distal tibia. Due to an insufficient understanding of this fracture, it is easy to cause missed diagnosis and misdiagnosis in clinical practice. Due to the insertion of the fracture, it is challenging to perform closed reduction, and improper treatment is easy to cause complications. Surgical treatment is recommended for this type of fracture. In order to improve the understanding of orthopedic surgeons about Bosworth fracture and dislocation, this paper reports the diagnosis and treatment of 2 cases of Bosworth fracture and dislocation, and reviews the literature on Bosworth fracture's mechanism, diagnosis, classification, complications, and treatment options in recent years.
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Affiliation(s)
- Dong-Peng Tu
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China.
| | - Li-Jun Cai
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Hong-Yong Zhao
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Li-Gang Huang
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
| | - Jing Nie
- Department of Orthopaedics, Hangzhou Xiaoshan Orthopaedic Hospital of Traditional Chinese Medicine, Hangzhou, 311261, China
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Fracture gap of the lateral malleolus via posterolateral approach: Improved visualization of the posterior malleolus fracture. Injury 2022; 53:3849-3852. [PMID: 36127174 DOI: 10.1016/j.injury.2022.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 02/02/2023]
Abstract
The treatment of posterior malleolar fractures is a popular issue. Anatomic reduction of posterior malleolar fractures is critical for re-establishing the stability of the ankle mortise and ligamentous union after trauma. Inappropriate treatment ultimately leads to poorer functional outcomes and lower quality of life. Open reduction and internal fixation through a posterolateral approach are preferred over indirect reduction and anterior-posterior screw fixation. Although the posterolateral approach, which is more common and direct, provides good exposure to the fracture site, it has some limitations. In this report, we describe the posterolateral approach through the lateral ankle fracture gap for the treatment of posterior ankle fractures. Moreover, we discuss the indications, benefits, and limitations of this approach.
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Fang C, Tang ZH, Yeoh CS, Tan GM. A Case Series of Bosworth Fracture-Dislocations and Review of 129 Reported Cases. Malays Orthop J 2022; 16:76-85. [PMID: 36589382 PMCID: PMC9791907 DOI: 10.5704/moj.2211.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/12/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Bosworth fracture dislocations of the ankle are rare injuries of the ankle caused by extreme external rotation of the supinated foot where the proximal fibula fracture fragment is posteriorly dislocated and entrapped behind the posterior-lateral ridge of the tibia. This case series aims to document three such cases treated in our institution over a nine year period. We also provide a review of 129 cases in the existing literature. Materials and methods Medical records and relevant radiographs for each patient were analysed and collected from the time of presentation till the point of latest follow-up. During each clinic visit, all physical exam findings as well as all complications were recorded. The American Foot and Ankle Society (AOFAS) Hindfoot score was also tabulated for each patient at the point of latest review. Results Closed reduction was unsuccessful in all three patients, and all required open reduction. One patient had an uncomplicated recovery whilst the remaining two suffered significant soft tissue complications. One patient suffered severe soft tissue swelling preventing primary closure at the time of surgery, whilst another suffered post-operative wound dehiscence and infection. Eventually all fractures healed, and all three patients obtained satisfactory AOFAS scores. Conclusion The diagnosis of Bosworth fracture dislocations of the ankle is often delayed or missed, due to its rare occurrence. Closed reduction is often unsuccessful, and early open reduction is required to avoid poor clinical outcomes due to severe soft tissue damage or even compartment syndrome.
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Affiliation(s)
- C Fang
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore,Corresponding Author: Christopher Fang, Department of Orthopaedic Surgery, National Healthcare Group, Singapore
| | - ZH Tang
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - CS Yeoh
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
| | - GM Tan
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore
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Müller E, Terstegen J, Kleinertz H, Weel H, Frosch KH, Barg A, Schlickewei C. [Established classification systems of posterior malleolar fractures : A systematic literature review]. Unfallchirurg 2022; 126:387-398. [PMID: 35394158 PMCID: PMC10159979 DOI: 10.1007/s00113-022-01162-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posterior malleolar fractures are found in almost 50% of all ankle fractures. The high clinical relevance of these joint fractures is explained by the significantly worse clinical and functional outcome. There is still a lack of unified opinion regarding the classification and treatment of these fractures. OBJECTIVE The aim of this article is to provide a systematic literature review of clinical studies that investigated posterior malleolar fractures and classified them using one of the three established classifications according to Haraguchi, Bartonicek/Rammelt, or Mason. MATERIAL AND METHODS PubMed was searched without time limits. The systematic literature search was performed according to the current criteria of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). The methodological quality of the included studies was quantified using the modified Coleman score. RESULTS A total of 27 studies with a total of 2220 patients were included in this systematic literature review. Trimalleolar fractures showed a significantly less favorable prognosis than other ankle fractures. The quality of reduction was the most important prognostic factor for the clinical outcome. CONCLUSION None of the three classifications examined has become established in the literature. Most of the classifications are weak or should not be used with respect to a derivable treatment algorithm or a prognosis with respect to the outcome. Only the classification according to Bartonicek/Rammelt is suitable to become established in the literature and in clinical practice due to its derivable treatment algorithm.
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Affiliation(s)
- Elena Müller
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Julia Terstegen
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Holger Kleinertz
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Hanneke Weel
- Orthopedics Center, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Karl-Heinz Frosch
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
| | - Alexej Barg
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Abteilung Unfallchirurgie, Orthopädie und Sporttraumatologie, BG Klinikum Hamburg, Hamburg, Deutschland
- Orthopädische Universitätsklinik, Universität von Utah, Salt Lake City, UT, USA
| | - Carsten Schlickewei
- Klinik und Poliklinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Bosworth fracture complicated by unrecognized compartment syndrome: a case report and review of the literature. Arch Orthop Trauma Surg 2022; 142:1435-1441. [PMID: 33598758 PMCID: PMC9217834 DOI: 10.1007/s00402-021-03815-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/01/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Compartment syndrome (CS) is exceedingly rare in ankle fractures. However, the risk of CS development seems to be increased in the presence of a Bosworth fracture-dislocation (BF), a rare variant of locked dislocation of the fibula behind the tibia. MATERIALS AND METHODS Here, we report the case of a 39-year old man with delayed diagnosis of CS after having sustained a BF and failed attempts on closed reduction. The patient developed a flexion contracture of the hallux necessitating secondary fusion. RESULTS At 3 years after the injury, the patient was capable of running, but had 10 degrees limitation of ankle dorsiflexion, persisting decreased sensation on the plantar surface and clawing of the lesser toes. A thorough review of the literature revealed nine cases of CS after 167 reported BF resulting in a calculated prevalence of 5.4%. CONCLUSIONS Given the extreme paucity of CS in malleolar fractures, CS in BF has a relatively high prevalence. Risk factors include severe dislocations, repeated attempts on closed reduction, and a long interval to definite surgery. A high index of suspicion is required because delayed diagnosis leads to lasting functional restrictions.
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Abstract
In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.
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Affiliation(s)
- Stefan Rammelt
- University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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Mittlmeier T, Saß M, Randow M, Wichelhaus A. [Fracture of the posterior malleolus : A paradigm shift]. Unfallchirurg 2021; 124:181-189. [PMID: 33512552 DOI: 10.1007/s00113-021-00954-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 12/27/2022]
Abstract
Ankle fractures with involvement of the posterior malleolus have a poor prognosis. The traditional concept of addressing the posterior fragment as the final step in the surgical reconstruction depending on the fragment size manifest in the lateral X‑ray, does not do justice to the anatomic and biomechanical relevance of the posterior malleolus. Intra-articular step-offs and fragment displacement ≥ 2 mm, impacted intercalary fragments, involvement of the fibular notch and instability of the syndesmosis, represent parameters relevant for the surgical reconstruction and the functional and radiomorphological outcome independent of fragment size. A valid assessment of these parameters can only be achieved via computed tomography (CT) including multiplanar 2D and 3D reconstruction. This is the foundation for the classification of posterior malleolar fractures according to Bartoníček et al., it forms the basis of the preoperative analysis of the fracture components and represents a decision-making tool for the indications for surgery. The individual fracture pattern guides the selection of the suitable approach or a combination of approaches and the surgical strategy. Making use of the posterior approaches enables the surgeon to have a direct view of the fracture components of the posterior malleolus as a precondition for an anatomic reduction. This central surgical step is frequently done as the first measure of the surgical reconstruction of the ankle joint. Furthermore, direct reduction and posterior stabilization is more accurate and stable than indirect reduction from an anterior approach with indirect fixation using lag screws. An additional temporary transfixation of the tibiofibular syndesmosis is often dispensable.
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Affiliation(s)
- T Mittlmeier
- Chirurgische Klinik und Poliklinik, Abt. für Unfall- Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
| | - M Saß
- Chirurgische Klinik und Poliklinik, Abt. für Unfall- Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - M Randow
- Chirurgische Klinik und Poliklinik, Abt. für Unfall- Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - A Wichelhaus
- Chirurgische Klinik und Poliklinik, Abt. für Unfall- Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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Han SJ, Kim JH, Yang DB, Kim BS, Ok HS. Bosworth-type fibular entrapment fracture of the ankle without dislocation: a rare case report and a review of the literature. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:178. [PMID: 33569480 PMCID: PMC7867949 DOI: 10.21037/atm-20-5112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Bosworth fracture-dislocation of ankle is a rare and irreducible type of ankle injury, with a high incidence of complication. This type of fracture was defined originally as entrapment of the proximal fragment of the fibula behind the posterior tubercle of the distal tibia. Recently, many variants of this type of fracture dislocation have been reported, but all of those reports included the syndesmosis ligament injury of ankle. Here, we report a case of a particularly rare variant of Bosworth fracture-dislocation without syndesmosis ligament injury of ankle. A 48-year-old male presented with a Bosworth fracture dislocation with entrapment of proximal fragment behind the tibia. After temporary treatment in emergency department was applied, emergency open reduction and internal fixation with a plate and screws was performed due to irreducibility of the fracture fragment. The fractured lateral malleolus was entrapped behind the tibia and rupture of the interosseous ligament was found intraoperatively. The anterior inferior tibiofibular ligament, a part of syndesmosis ligament of ankle, was grossly intact and no abnormal findings was seen by fluoroscopy with external rotational stress. Moreover, the deltoid ligament was found to be normal in ultrasonography. There were no complications after surgery and the patient showed full functional recovery at 2 years follow up. These fractures will frequently be irreducible and should be considered for open reduction and internal fixation with the careful evaluation of injury mechanisms with syndesmotic stability.
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Affiliation(s)
- Sang-Jin Han
- Departments of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, Korea
| | - Jong-Heon Kim
- Departments of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, Korea
| | - Du-Bin Yang
- Departments of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, Korea
| | - Boo-Seop Kim
- Departments of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, Korea
| | - Hyun-Soo Ok
- Departments of Orthopedic Surgery, Hyundae General Hospital, Chung-Ang University, Namyangju-Si, Kyunggi-Do, Korea
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