A survey of the management of posterior malleolar ankle fractures in South Africa



trimalleolar ankle fracture, open reduction of posterior malleolus, syndesmosis injury, Haraguchi classification, CT scan of ankle fractures


Background: Posterior malleolus fractures are associated with poorer functional outcomes compared to simpler malleolar fractures. Traditional teaching states that if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation. Current literature has shown that fixation should not be based on the size of the posterior fragment but rather on the fracture pattern, instability and awareness that reduction and fixation is biomechanically advantageous. We hypothesised that current management of ankle fractures with posterior malleolus involvement in South Africa is not evidence-based and is suboptimal. We sought to assess the training, experience and decision-making of surgeons and trainees who are involved in the management of ankle fractures. Another aim was to develop evidence-based algorithms for the management of posterior malleolus and complex ankle fractures.

Methods: An email survey consisting of questions related to the management of ankle fractures was sent to specialists, registrars and medical officers who voluntarily completed an online survey.

Results: A total of 103 out of 456 emails sent drew responses to the survey. Responses included 28% from consultants, 54% from registrars and 18% from medical officers. Forty-six per cent of responders believed that posterior malleolus fractures can be managed non-operatively if less than 20% of the tibial plafond is involved. Only 49% would CT scan a posterior malleolus prior to operating. Thirty-eight per cent of the responders were not familiar or comfortable with the posterior-lateral approach used for fixation of the posterior malleolus directly.

Conclusion: Understanding of ankle fractures has progressed. A significant proportion of responders to the survey are not following best practice and current literature. Posterior malleolus fractures are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. All patients with posterior malleolus fractures should receive pre-operative CT scan. All posterior malleolar fractures that can be held with a plate or screws should be fixed.

Level of evidence: Level 5

Author Biographies

M I Workman, University of Cape Town

BSc Physio, MBBCh; Registrar, Department of Orthopaedics, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

G S Wever, University of Cape Town

MBBCh; Registrar, Department of Orthopaedics, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

G A McCollum, University of Cape Town

MBChB, MMed(UCT), FC Orth SA; Consultant, Department of Orthopaedics, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa