Medial malleolar fractures

Medial Malleolar Fractures

 

Medial Malleolus Fracture

 

Epidemiology

 

Isolated medial malleolus fractures 3% of ankle fractures

 

Herscovici Classification

 

Type A: Avulsion

Type B: Between tip and plafond

Type C: At level of plafond

Type D: Vertical fracture

 

Management

 

Isolated medial malleolar fractures

 

Lokerman et al J Foot Ankle Surg 2019

- systematic review of 18 studies and 2500 patients

- isolated medial malleolar fractures

- ORIF: nonunion 1.7%

- cast: nonunion 3.5%

 

Herscovici et al JBJS Br 2007

- 57 isolated medial malleolar fractures treated in a cast

- mean displacement 3.8 mm

- 55/57 united

- 2 nonunions with 3 - 4 mm displacement required ORIF + bone graft

 

Hanhisuanto et al Foot Ankle Surg 2017

- isolated medial malleolar fractures

- 60 treated with surgery: mean displacement 2 mm

- 53 non operative: mean displacement 1 mm

- worse outcomes with non operative management > 2 mm displacement

 

Bimalleolar / Trimalleolar fractures

 

Carter et al JAMA Netw Open 2024

- RCT of operative versus nonoperative medial malleolus

- 144 patients with ORIF fibular +/- posterior malleolus

- medial malleolus in satisfactory position

- nonunion: fixation 0%, non operative 20% (1/13 required surgery)

 

Displaced

- ORIF

- 20% risk of non union

 

Undisplaced

- can usually manage in cast

- still small risk of non union

 

Approaches

 

AO surgery reference posteromedial approach ankle

 

Fixation options

Large fracture Small fracture Vertical fracture
2 partially threaded screws Tension band wire Buttress plate
Ankle Fracture Medial Malleolus 2 Screws Ankle Fracture Medial Malleolus TBW MM plate

 

Non-union

 

Medial Malleolus Non union