title: The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures.
abstract: OBJECTIVE
  Despite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention.
  
  
  METHODS
  A questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus.
  
  
  RESULTS
  The cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35 % (62) of participants, whereas 65 % (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79 % (140) suggested operative intervention and only 21 % (37) advocated nonoperative management (p = 0.03).
  
  
  CONCLUSIONS
  Most surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.
authors.affiliation: Orthopedics Department, Foot and Ankle Service, Meir Medical Center, Sacker School of Medicine Tel Aviv University, Kfar-Saba, Israel, ezepalm@gmail.com.
authors.forename: Ezequiel
authors.initials: E
authors.lastname: Palmanovich
authors.forename: Yaron S
authors.initials: YS
authors.lastname: Brin
authors.forename: Lior
authors.initials: L
authors.lastname: Laver
authors.forename: Benny
authors.initials: B
authors.lastname: Kish
authors.forename: Meir
authors.initials: M
authors.lastname: Nyska
authors.forename: Iftach
authors.initials: I
authors.lastname: Hetsroni
mesh_terms: D064386:Ankle Fractures / Q000473:pathology / Q000601:surgery*; D003657:Decision Making; D006801:Humans; D019637:Orthopedic Procedures / Q000379:methods; D009985:Orthopedics; D010818:Practice Patterns, Physicians'; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed