PURPOSE: Bosworth fracture-dislocations (BF) with entrapment of a fibular fragment behind the posterior rim of the distal tibia are rare but potentially serious injuries to the ankle. MATERIALS AND METHODS: We analyzed the radiographs of 23 consecutive patients with a mean age of 44 years who were treated for BF. All patients underwent routine radiological examination of the ankle and presence of a BF was confirmed intraoperatively in 22 cases and / or with CT in 15 cases. RESULTS: Tibiofibular overlap intersecting the joint line in the anteroposterior view of the ankle was found in 20 of 23 cases (87%) and persisted in 17 of 18 cases (94%) after unsuccessful closed reduction. Posterior subluxation of the talus in the lateral view was revealed in 21 of 23 cases (91%). Tibio-fibular dissociation, i.e., posterior displacement of the distal fibula relative to the distal tibia in the lateral view was found in 22 of 23 cases (96%). This sign remained positive in all 18 cases with unsuccessful closed reduction. Closed reduction of the talus beneath the distal tibia was associated with an average increase of anterior fibular angulation of 24.5 degrees in case of inadequate closed reduction. CONCLUSIONS: Bosworth fracture represents a rare but still highly variable ankle injury that may lead to misinterpretation of the initial radiographs. Reliable radiological signs are triangular tibiofibular overlap, posterior talar subluxation and tibiofibular dissociation that should prompt CT imaging which is essential for revealing the complex pathoanatomy and planning the surgical approach.

• Klíčová slova
• Ankle fracture-dislocations, Bosworth fracture, CT diagnostics, Posterior malleolus,
• MeSH
• dislokovaná fraktura * diagnostické zobrazování   chirurgie   MeSH
• dospělí MeSH
• fibula * zranění   diagnostické zobrazování   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• fraktury tibie * diagnostické zobrazování   chirurgie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• počítačová rentgenová tomografie MeSH
• poranění kotníku * diagnostické zobrazování   chirurgie   MeSH
• radiografie MeSH
• reprodukovatelnost výsledků MeSH
• retrospektivní studie MeSH
• senioři MeSH
• vnitřní fixace fraktury metody   MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

• Klíčová slova
• Ankle anatomy, Colliculi, Deltoid ligament, Fractures of medial malleolus, Medial malleolus,
• Publikační typ
• časopisecké články MeSH

Bosworth fracture (BF) is a special type of locked ankle fracture-dislocation, characterized by displacement of a fragment of the fractured fibula from the fibular notch behind the posterior surface of the distal tibia. BF is a complex injury affecting multiple structures of the ankle joint, which is still frequently misjudged even today, potentially leading to severe complications. CT examination, including 3D reconstructions, should be the diagnostic standard in BF, as it provides a complete picture of the fracture pathoanatomy, most prominently the morphology of the frequently associated posterior malleolar fracture. BF requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction. Non-operative treatment of BF almost always fails. The standard treatment procedure is early open reduction internal fixation. Due to the relative severity and paucity of the injury, BF seems to be particularly prone to soft tissue complications, including compartment syndrome. The results of operative treatment are mixed. Many studies report persistent pain even after a short time interval, with limitations of the range of motion or even stiffness of the ankle joint, and development of degenerative changes. Larger studies with long-term results are still missing.

• Klíčová slova
• Ankle fracture, Bosworth fracture, compartment syndrome, posterior malleolus fracture,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

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.

• Klíčová slova
• Fibular notch, Maisonneuve fracture, Posterior malleolus, Tillaux–Chaput tubercle,
• MeSH
• dislokovaná fraktura diagnostické zobrazování   MeSH
• dospělí MeSH
• fibula zranění   diagnostické zobrazování   MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• incidence MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• počítačová rentgenová tomografie MeSH
• prospektivní studie MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mladý dospělý MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

INTRODUCTION: Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures. MATERIALS AND METHODS: A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartoníček/Rammelt et al., and Mason et al. was investigated. RESULTS: ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartoníček/Rammelt type 2 fractures, the most common fracture type. Bartoníček/Rammelt type 3 fractures had the highest relative frequency of ICFs. CONCLUSION: ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

• Klíčová slova
• Ankle fracture, Bartoníček/Rammelt, Intercalary fragment, Posterior malleolar fracture,
• MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• incidence MeSH
• lidé středního věku MeSH
• lidé MeSH
• počítačová rentgenová tomografie MeSH
• retrospektivní studie MeSH
• tibie MeSH
• vnitřní fixace fraktury MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

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.

• Klíčová slova
• Ankle, Compartment syndrome, Fasciotomy, Fracture, Locked dislocation,
• MeSH
• dislokace kloubu * chirurgie   MeSH
• dislokovaná fraktura * komplikace   diagnostické zobrazování   chirurgie   MeSH
• dospělí MeSH
• fibula chirurgie   MeSH
• fraktury kotníku * chirurgie   MeSH
• kompartment syndrom * diagnóza   etiologie   chirurgie   MeSH
• lidé MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• mužské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• přehledy MeSH

OBJECTIVE: The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. INDICATIONS: Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. CONTRAINDICATIONS: Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. SURGICAL TECHNIQUE: Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3). POSTOPERATIVE MANAGEMENT: Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. RESULTS: Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

ZUSAMMENFASSUNG: OPERATIONSZIEL: Die Tibiavorderkante mit dem Tuberculum anterius tibiae dient als Ansatz für das Lig. tibiofibulare anterius. Sie kann als vorderer oder „vierter“ Knöchel bezeichnet werden. Ziel der Osteosynthese dislozierter Fragmente ist die knöcherne Stabilisierung der vorderen Syndesmose und die Wiederherstellung der Incisura tibiae für die distale Fibula. INDIKATIONEN: Dislozierte Gelenkfrakturen der Tibiavorderkante, Frakturen mit Verwerfung der vorderen Tibiainzisur, Frakturen mit Intermediärfragment(en), Impression des vorderen Tibiaplafonds, instabile Avulsionen des Lig. tibiofibulare anterius oder in den Syndesmosenspalt eingeschlagene Fragmente. KONTRAINDIKATIONEN: Kritische Weichteilverhältnisse im Zugangsbereich, Ablehnung der Operation durch den Patienten, kritischer Allgemeinzustand des Patienten. OPERATIONSTECHNIK: Anterolateraler Zugang über dem Tuberculum anterius tibiae. Identifikation und Mobilisierung des Tibiavorderkantenfragments ohne Dissektion des Lig. tibifibulare anterius. Reposition des Fragments mit einer spitzen Repositionszange. Fixierung extraartikulärer Avulsionsfrakturen mit Nahtanker. Schraubenosteosynthese größerer Fragmente mit Beteiligung der Gelenkfläche und Inzisur. Anhebung, Wiederherstellung der Gelenkfläche, Spongiosaplastik, wenn erforderlich, und anteriore Plattenosteosynthese von Impressionsfrakturen des vorderen Tibiaplafonds. WEITERBEHANDLUNG: Mobilisation im Verbandsstiefel oder Castverband mit Teilbelastung (15–20 kg) für 6–8 Wochen je nach Frakturmuster, Knochenqualität und Patientencompliance. ERGEBNISSE: Nur wenige Studien berichten über Resultate nach der Osteosynthese von Tibiavorderkantenfrakturen bei Erwachsenen. Bei ausbleibender Fixierung dislozierter Fragmente werden Pseudarthrosen beschrieben. Bei der Versorgung von Sprunggelenkfrakturen übersehene Tibiavorderkantenfragmente können zu einer Fehlplatzierung der distalen Fibula in der Incisura fibularis tibiae mit nachfolgender Inkongruenz der Knöchelgabel und der Notwendigkeit von Revisionsoperationen führen. Sekundäre avaskuläre Nekrosen des anterolateralen Tibiaplafonds können nach Impaktionsverletzungen entstehen.

• Klíčová slova
• Ankle fracture, Growth plate, Joint impaction, Malleolar fracture, Syndesmosis,
• MeSH
• dospělí MeSH
• fibula MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• fraktury tibie * diagnostické zobrazování   chirurgie   MeSH
• lidé MeSH
• tibie MeSH
• vnitřní fixace fraktury MeSH
• výsledek terapie MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

The anterolateral tibial rim with the anterior tibial tubercle (Tubercule de Tillaux-Chaput) serves as an insertion site of the anterior inferior tibiofibular ligament (AITFL). It can also be termed the anterior malleolus or fourth malleolus. Fractures of the anterolateral tibial rim typically result from an external rotation or abduction mechanism of the talus within the ankle mortise. They are frequently overlooked in plain radiographs. Computed tomography (CT) is needed for an exact visualization of the fracture anatomy and treatment planning. A total of three main types can be differentiated: (1) extra-articular avulsion fracture of the AITFL, (2) fracture of the anterolateral distal tibia with involvement of the joint and tibial incisura and (3) impaction fracture of the anterolateral tibial plafond. Surgical fixation of displaced anterolateral distal tibial fractures aims at bone-to-bone stabilization of the anterior syndesmosis, restoration of the tibial incisura for the distal fibula and joint surface. Displaced extra-articular avulsion fractures (type 1) are fixed with a suture anchor or transosseal suture. Larger fragments involving the tibial incisura and plafond (type 2) are mostly fixed with screws. Impression fractures of the anterolateral tibial plafond (type 3) necessitate elevation with restoration of the joint surface, bone grafting of the impaction zone as needed and anterior buttress plating. Only a few studies have reported the treatment results of anterolateral tibial rim fractures in adults. Conservative treatment of dislocated fragments reportedly leads to non-union and malposition of the distal fibula with incongruence of the ankle mortise requiring revision. Impaction fractures (type 3) can lead to secondary avascular necrosis of the anterolateral tibial plafond.

Die laterale Tibiavorderkante mit dem Tuberculum anterius tibiae (Tubercule de Tillaux-Chaput) dient als Ansatz für das Lig. tibiofibulare anterius. Sie kann auch als Malleolus anterior oder vierter Knöchel bezeichnet werden. Frakturen der lateralen Tibiavorderkante entstehen mehrheitlich durch einen Außenrotations- oder Abduktionsmechanismus im oberen Sprunggelenk. Sie werden in Röntgenaufnahmen häufig übersehen. Zur genauen Darstellung der Frakturanatomie und Therapieplanung ist eine CT erforderlich. Es können 3 prinzipielle Typen unterschieden werden: (1) extraartikuläre Avulsionen des vorderen Syndesmosenbandes, (2) Frakturen der anterolateralen distalen Tibia mit Beteiligung von Gelenk und/oder Tibiainzisur, (3) Impaktionsfrakturen des anterolateralen Tibiaplafonds. Die Osteosynthese dislozierter Frakturen der lateralen Tibiavorderkante dient der knöchernen Stabilisierung der vorderen Syndesmose, der Wiederherstellung der Incisura tibiae für die distale Fibula und Gelenkfläche. Dislozierte extraartikuläre Avulsionsfrakturen (Typ 1) werden mithilfe eines Nahtankers oder einer transossären Naht refixiert. Bei größeren Fragmenten mit Beteiligung der Gelenkfläche und Inzisur (Typ 2) erfolgt vorzugsweise eine Schraubenosteosynthese. Impressionsfrakturen des anterolateralen Tibiaplafonds (Typ 3) erfordern die Anhebung mit Wiederherstellung der Gelenkfläche, ggf. eine Spongiosaplastik und eine anteriore Plattenosteosnythese. Es existieren nur wenige Daten über die Behandlungsergebnisse von Tibiavorderkantenfrakturen bei Erwachsenen. Bei konservativer Therapie dislozierter Fragmente werden Pseudarthrosen und revisionspflichtige Fehlstellungen mit Inkongruenz der Knöchelgabel beschrieben. Nach Impaktionsverletzungen (Typ 3) können sekundäre avaskuläre Nekrosen des anterolateralen Tibiaplafonds entstehen.

• Klíčová slova
• Ankle joint, Anterior malleolus, Internal fixation, Tibiofibular syndesmosis, Tillaux fracture,
• MeSH
• dospělí MeSH
• fibula MeSH
• fraktury kotníku * diagnostické zobrazování   chirurgie   MeSH
• fraktury tibie * diagnostické zobrazování   chirurgie   MeSH
• lidé MeSH
• ligamentum laterale articulationis talocruralis * MeSH
• tibie MeSH
• vnitřní fixace fraktury MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

• Klíčová slova
• Ankle fractures, Classification of posterior malleolar fractures, Posterior malleolus, Trimalleolar fractures,
• MeSH
• biomechanika fyziologie   MeSH
• dislokace kloubu chirurgie   MeSH
• fraktury kotníku diagnostické zobrazování   patofyziologie   chirurgie   MeSH
• kloubní ligamenta zranění   chirurgie   MeSH
• kostní dráty MeSH
• kostní šrouby MeSH
• lidé MeSH
• nestabilita kloubu etiologie   prevence a kontrola   MeSH
• počítačová rentgenová tomografie MeSH
• pooperační komplikace etiologie   MeSH
• vnitřní fixace fraktury přístrojové vybavení   metody   MeSH
• výsledek terapie MeSH
• zobrazování trojrozměrné MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH