title: Posterior Malleolar Fractures Associated With Tibial Shaft Fractures and Sequence of Fixation.
abstract: OBJECTIVE
  The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers.
  
  
  METHODS
  Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation.
  
  
  METHODS
  Intraoperative displacement, quality of reduction.
  
  
  RESULTS
  Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01).
  
  
  CONCLUSIONS
  Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern.
  
  
  METHODS
  Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA; †Department of Health Research, Geisinger Research Center, Danville, PA; ‡Department of Orthopaedics, University of Utah, Salt Lake City, UT; and §Department of Orthopaedics, Boston University Medical Center, Boston, MA.
authors.forename: Harish
authors.initials: H
authors.lastname: Kempegowda
authors.forename: Hemil H
authors.initials: HH
authors.lastname: Maniar
authors.forename: Raveesh
authors.initials: R
authors.lastname: Richard
authors.forename: Akhil
authors.initials: A
authors.lastname: Tawari
authors.forename: Graham
authors.initials: G
authors.lastname: Jove
authors.forename: Michael
authors.initials: M
authors.lastname: Suk
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Beebe
authors.forename: Chris
authors.initials: C
authors.lastname: Han
authors.forename: Paul
authors.initials: P
authors.lastname: Tornetta
authors.forename: Erik N
authors.initials: EN
authors.lastname: Kubiak
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Horwitz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D064386:Ankle Fractures / Q000150:complications / Q000601:surgery*; D005260:Female; D005592:Fracture Fixation / Q000379:methods*; D005594:Fracture Fixation, Intramedullary / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000150:complications / Q000601:surgery*; D055815:Young Adult