Skip to main content
SpringerLink
Log in

Intra-articular fracture patterns associated with tibial shaft fractures: more than just the posterior malleolus

  • Original Article
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Background

The association of tibial shaft fractures (TSFs) with posterior malleolar fractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distal intra-articular fractures in TSFs.

Methods

All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures.

Results

405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3–4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5–4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0–9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury.

Conclusions

Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury.

Level of Evidence

Diagnostic Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Sobol GL, Kareem Shaath M, Reilly MC et al (2018) The incidence of posterior malleolar involvement in distal spiral tibia fractures: is it higher than we think? J Orthop Trauma 32:543–547. https://doi.org/10.1097/BOT.0000000000001307

    Article  PubMed  Google Scholar 

  2. Kukkonen J, Heikkilä JT, Kyyrönen T et al (2006) Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study. J Trauma 60:1058–1060. https://doi.org/10.1097/01.TA.0000196700.74272.10

    Article  PubMed  Google Scholar 

  3. Boraiah S, Gardner MJ, Helfet DL, Lorich DG (2008) High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res 466:1692–1698. https://doi.org/10.1007/S11999-008-0224-5

    Article  PubMed  PubMed Central  Google Scholar 

  4. Kempegowda H, Maniar HH, Richard R et al (2016) Posterior malleolar fractures associated with tibial shaft fractures and sequence of fixation. J Orthop Trauma 30:568–571. https://doi.org/10.1097/BOT.0000000000000629

    Article  PubMed  Google Scholar 

  5. Mitchell PM, Harms KA, Lee AK, Collinge CA (2019) Morphology of the posterior malleolar fracture associated with a spiral distal tibia fracture. J Orthop Trauma 33:185–188. https://doi.org/10.1097/BOT.0000000000001398

    Article  PubMed  Google Scholar 

  6. Hendrickx LAM, Cain ME, Sierevelt IN et al (2019) Incidence, predictors, and fracture mapping of (Occult) posterior malleolar fractures associated with tibial shaft fractures. J Orthop Trauma 33:e452–e458. https://doi.org/10.1097/BOT.0000000000001605

    Article  PubMed  Google Scholar 

  7. Fisher ND, Bi AS, Parola R et al (2022) Fracture obliquity angle and distance from plafond: novel radiographic predictors of posterior malleolar involvement in tibial shaft fractures. Eur J Orthop Surg Traumatol. https://doi.org/10.1007/S00590-022-03371-3

    Article  PubMed  Google Scholar 

  8. Bi AS, Fisher ND, Parola R et al (2022) Can we predict size, Haraguchi type and preoperative displacement of posterior malleolar fractures in association with tibial shaft fractures? Eur J Orthop Surg Traumatol. https://doi.org/10.1007/S00590-022-03327-7

    Article  PubMed  Google Scholar 

  9. Jung KJ, Chung CY, Park MS et al (2015) Concomitant ankle injuries associated with tibial shaft fractures. Foot Ankle Int 36:1209–1214. https://doi.org/10.1177/1071100715588381

    Article  PubMed  Google Scholar 

  10. Behlmer RJ, Simske NM, Graf RM et al (2021) Diagnosing fractures of the distal tibial articular surface in tibia shaft fractures: is computed tomography always necessary? J Orthop Trauma 35:485–489. https://doi.org/10.1097/BOT.0000000000002135

    Article  PubMed  Google Scholar 

  11. Marchand LS, Rane AA, Working ZM et al (2017) Radiographic investigation of the distal extension of fractures into the articular surface of the tibia (The RIDEFAST Study). J Orthop Trauma 31:668–674. https://doi.org/10.1097/BOT.0000000000000938

    Article  PubMed  Google Scholar 

  12. Rane A, Jacobson LG, Kellam P et al (2021) External validation of the radiographic investigation of the distal extension of fractures into the articular surface of the tibia (RIDEFAST Study). J Orthop Trauma 35:479–484. https://doi.org/10.1097/BOT.0000000000002044

    Article  PubMed  Google Scholar 

  13. Georgiadis GM, Ebraheim NA, Hoeflinger MJ (1996) Displacement of the posterior malleolus during intramedullary tibial nailing. J Trauma 41:1056–1058. https://doi.org/10.1097/00005373-199612000-00022

    Article  CAS  PubMed  Google Scholar 

  14. Hendrickx LAM, Sobol GL, Langerhuizen DWG et al (2020) A machine learning algorithm to predict the probability of (occult) posterior malleolar fractures associated with tibial shaft fractures to guide “malleolus first” fixation. J Orthop Trauma 34:131–138. https://doi.org/10.1097/BOT.0000000000001663

    Article  PubMed  Google Scholar 

  15. Wang Z, Chen W, Zhu Y et al (2021) Incidence and missed diagnosis risk of occult posterior malleolar fractures associated with the tibial shaft fractures: a systematic review. J Orthop Surg Res. https://doi.org/10.1186/s13018-021-02502-6

    Article  PubMed  PubMed Central  Google Scholar 

  16. Zhang K, Cui R, Gu Y et al (2020) Posteroanterior lag screws versus posterior buttress plate fixation of posterior malleolar fragments in spiral tibial shaft fracture. J Foot Ankle Surg 59:768–773. https://doi.org/10.1053/J.JFAS.2019.09.039

    Article  PubMed  Google Scholar 

  17. Meinberg EG, Agel J, Roberts CS et al (2018) Fracture and dislocation classification compendium-2018. J Orthop Trauma 32:S1–S170. https://doi.org/10.1097/BOT.0000000000001063

    Article  PubMed  Google Scholar 

  18. Haraguchi N, Haruyama H, Toga H, Kato F (2006) Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 88:1085–1092. https://doi.org/10.2106/JBJS.E.00856

    Article  PubMed  Google Scholar 

  19. Team. RC (2020) R: A language and environment for statistical computing. In: R: Foundation for Statistical Computing

  20. Bidolegui F, Pereira S, Garabano G et al (2022) Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases. Eur J Orthop Surg Traumatol. https://doi.org/10.1007/S00590-021-03188-6

    Article  PubMed  Google Scholar 

  21. Kellam PJ, Haller JM, Rothberg DL et al (2019) Posterior malleolar fracture morphology in tibial shaft versus rotational ankle fractures: the significance of the computed tomography scan. J Orthop Trauma 33:e459–e465. https://doi.org/10.1097/BOT.0000000000001601

    Article  PubMed  Google Scholar 

  22. Ding BTK, Pillay K, Sechachalam S (2018) Radial shaft fracture obliquity as a predictor of distal radioulnar joint instability. J Hand Surg Eur 43:732–738. https://doi.org/10.1177/1753193418756591

    Article  Google Scholar 

  23. Rettig ME, Raskin KB (2001) Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg Am 26:228–235. https://doi.org/10.1053/JHSU.2001.21523

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

No funding was received to assist with the preparation of this manuscript.

Author information

Authors and Affiliations

  1. NYU Langone Orthopedic Hospital, 301 E 17th St, NY, 10003, New York, USA

    Nina D. Fisher, Andrew S. Bi, Rown Parola, Abhishek Ganta, Sanjit Konda & Kenneth A. Egol

  2. Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Richmond Hill, NY, 11418, USA

    Abhishek Ganta, Sanjit Konda & Kenneth A. Egol

Authors
  1. Nina D. Fisher
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andrew S. Bi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rown Parola
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Abhishek Ganta
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sanjit Konda
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kenneth A. Egol
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kenneth A. Egol.

Ethics declarations

Conflict of interest

Sanjit Konda is a consultant for Stryker. Kenneth Egol is a consultant for Exactech and Synthes, receives royalties from Exactech, Wolters Kluwer and Slack Inc, receives research support from Synthes and Acumed, and is a paid lecturer for Smith and Nephew. The remaining authors have no relevant financial or non-financial interests to disclose.

Ethical approval

Institutional Review Board (IRB) approval was obtained.

Informed consent

Informed consent was waived per IRB guidelines due to retrospective nature of study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fisher, N.D., Bi, A.S., Parola, R. et al. Intra-articular fracture patterns associated with tibial shaft fractures: more than just the posterior malleolus. Eur J Orthop Surg Traumatol 33, 2283–2290 (2023). https://doi.org/10.1007/s00590-022-03421-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-022-03421-w

Keywords

Search

Navigation