We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ("quadrimalleolar") or anterior fibular rim ("quadrimalleolar equivalent"). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15-156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45-100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39-100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.

Department of Orthopaedics 1st Faculty of Medicine Charles University and Central Military Hospital Prague Czech Republic

University Center for Orthopaedics Trauma and Plastic Surgery University Hospital Carl Gustav Carus at TU Dresden Dresden Germany; and

Zobrazit více v PubMed

Henderson MS. Trimalleolar fracture of the ankle. Surg Clin North Am. 1932;12:867–872.

Destot E. Traumatismes du Pied et Rayons X. Malleoles, Astragale, Calcaneum, Avant-pied. Paris: Masson; 1911:1–10.

Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565–1570.

Tejwani NC, Pahk B, Egol KA. Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma. 2010;69:666–669.

Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures of the ankle. Changing concepts and recent developments. Foot Ankle Clin. 2017;22:125–145.

Heim D, Niederhauser K, Simbrey N. The Volkmann dogma: a retrospective, long-term, single-center study. Eur J Trauma Emerg Surg. 2010;36:515–519.

Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88:1085–1092.

Bartoníček J, Rammelt S, Kostlivý K, et al. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg. 2015;135:505–516.

Miller AN, Carroll EA, Parker RJ, et al. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010;468:1129–1135.

Sultan F, Zheng X, Pan Z, et al. Characteristics of intercalary fragment in posterior malleolus fractures. Foot Ankle Surg. 2020;26:289–294.

Tillaux P. Recherches cliniques et experimentales sur les fractures malleolaires. Rapport par Gosselin. Bull Acad Med. 1872;21:817–826.

Chaput V. Les Fractures Malléolaires Du Cou-de-Pied et Les Accidents Du Travail. Paris: Masson; 1907.

Rammelt S, Boszczyk A. Computed tomography in the diagnosis and treatment of ankle fractures: a critical analysis review. JBJS Rev. 2018;6:e7.

Marx C, Schaser KD, Rammelt S. Early corrections after failed ankle fracture fixation. Z Orthop Unfallchir. 2020. doi: 10.1055/a-1079-6476. [epub ahead of print]. DOI

Van Laarhoven CJ, Oostvogel HJ, van der Werken C. Differentiated protocol for the conservative/surgical treatment of ankle fractures in adults [in Dutch]. Ned Tijdschr Geneeskd. 1996;140:2342–2349.

Rammelt S, Swords M, Dhillon M, et al, eds. Manual of Fracture Management. Foot and Ankle. Stuttgart, Germany and New York, NY: Thieme and Davos, AO Foundation; 2020.

Wagstaffe WW. An unusual form of fracture of the fibula. St Thomas Hosp Rep. 1875;6:43.

LeFort L. Note sur une variete non-decrite de fracture verticale de la malleole externe par arrachement. Bull Gen Ther. 1886:193–199.

Park JW, Kim SK, Hong JS, et al. Anterior tibiofibular ligament avulsion fracture in Weber type B lateral malleolar fracture. J Trauma. 2002;52:655–659.

Haraguchi N, Toga H, Shiba N, et al. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med. 2007;35:1144–1152.

Rammelt S, Zwipp H, Mittlmeier T. Operative treatment of pronation fracture-dislocations of the ankle. Oper Orthop Traumatol. 2013;25:273–293.

Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg. 2015;41:601–614.

Baumbach SF, Herterich V, Damblemont A, et al. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury. 2019;50:564–570.

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;26:281–285.

Heim U, Pfeiffer KM. Internal Fixation of Small Fractures. Technique Recommended by the AO-ASIF Group. Berlin, Heidelberg, New York: Springer; 1988.

Lees D, Rankin KS, Marriott A, et al. Floppy lateral position: technique tip. Foot Ankle Int. 2013;34:1460–1463.

Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957–985.

Rodriguez EK, Kwon JY, Herder LM, et al. Correlation of AO and Lauge-Hansen classification systems for ankle fractures to the mechanism of injury. Foot Ankle Int. 2013;34:1516–1520.

Boszczyk A, Fudalej M, Kwapisz S, et al. X-ray features to predict ankle fracture mechanism. Forensic Sci Int. 2018;291:185–192.

Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma. 2018;32(suppl 1):S1–S170.

Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018;39:99–104.

Kennedy JG, Soffe KE, Dalla Vedova P, et al. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma. 2000;14:359–366.

Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19:102–108.

Langenhuijsen JF, Heetveld MJ, Ultee JM, et al. Results of ankle fractures with involvement of the posterior tibial margin. J Trauma. 2002;53:55–60.

Andersen MR, Diep LM, Frihagen F, et al. Importance of syndesmotic reduction on clinical outcome after syndesmosis injuries. J Orthop Trauma. 2019;33:397–403.

Verhage SM, Boot F, Schipper IB, et al. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J. 2016;98-B:812–817.

Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. Foot Ankle Int. 2015;36:673–678.

Birnie MFN, van Schilt KLJ, Sanders FRK, et al. Anterior inferior tibiofibular ligament avulsion fractures in operatively treated ankle fractures: a retrospective analysis. Arch Orthop Trauma Surg. 2019;139:787–793.

Boszczyk A, Kordasiewicz B, Kiciński M, et al. Operative setup to improve sagittal syndesmotic reduction - technical tip. J Orthop Trauma. 2019;33:e27–e30.

Geerling J, Mittlmeier T, Richter M, et al. Intraoperative three-dimensional imaging for syndesmotic injuries—a multicenter study of the AG Fuß of the DGU. FussSprungg. 2016;14:79–93.

Shi HF, Xiong J, Chen YX, et al. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord. 2017;18:109.

McGoldrick NP, Murphy EP, Kearns SR. Single oblique incision for simultaneous open reduction and internal fixation of the posterior malleolus and anterior syndesmosis. J Foot Ankle Surg. 2016;55:664–667.

Bosworth ankle fracture-dislocation: current concept review

"Double Maisonneuve fracture": an unknown fracture pattern

Frakturen der lateralen Tibiavorderkante : Der vierte Knöchel