The Institutional Review Board approved the study protocol.īecause we encountered one patient with a delayed diagnosis and one with a missed injury, we instituted a protocol in June 2006 to better identify injuries. We judged the 3-month minimum an appropriate interval to subsequently detect a clinically relevant ankle fracture if it had not been previously identified. The minimum followup was 3 months (mean, 25 months range, 3–68 months). Thirteen injuries were the result of high-velocity mechanisms, eight of which were motor vehicle accidents and five were from a fall from a height. Thirty-seven patients had spiral tibial fractures (42A-1) (61.2%), 12 had oblique fractures (42A-2) (19%), and three had transverse fractures (42A-3) (4.8%). The mean age of the patients at presentation was 45 years (range, 18–76 years) and 42 patients were men. Of these, 62 had fractures of the distal third of the diaphysis and formed the study cohort. We identified 114 consecutive patients with a tibial diaphyseal shaft fracture between March 2002 and August 2007. Given the controversy in the literature on the incidence of associated posterior malleolus fractures, we first determined the incidence of posterior malleolus fractures and second evaluated the efficacy of a diagnostic protocol designed to improve detection and treatment of these associated injuries. Early knee and ankle mobilization is crucial to prevent postsurgical stiffness, and thus stable fixation of the posterior malleolus is particularly important in combined injuries. Although various treatment options have been described, two studies advocated internal fixation when associated with tibial shaft and ipsilateral ankle fractures. Unrecognized posterior malleolus fractures may displace during reduction maneuvers or with intramedullary reaming or nailing and during the postoperative period as a result of aggressive range of motion exercises of the ankle and early weightbearing. Most likely, the variably reported rates are secondary to increased detection with improved imaging quality and increased awareness of the association. A more recent study reported a higher incidence of 25%. Van der Werken and Zeegers, however, reported a rate of 11.5%. Bostman reported a 0.6% incidence of concurrent ankle fractures with tibial fractures. The association between the two injuries, however, remains unclear. The combination of a tibial shaft fracture and posterior malleolus fracture is a well-known entity that can have a substantial impact on treatment approaches. See the Guidelines for Authors for a complete description of levels of evidence. Level of Evidence: Level II, prognostic study. A protocol including computed tomography of the ankle may detect more injuries in a larger study. A spiral distal tibial shaft fracture with a proximal fibula fracture should alert the surgeon to investigate an occult ankle injury, particularly of the posterior malleolus. Before initiation of the protocol, intraarticular fractures were recognized in 33% (with one delayed diagnosis and one missed diagnosis), and after institution of the protocol, the detection rate was 48% with no known missed injuries and complete followup however, with the limited power the detection rates were similar without and with the protocol. Twenty-four patients (39%) had fractures of the posterior malleolus. Of 62 consecutive patients with fractures of the distal third of the tibia, we retrospectively evaluated the first 39 patients and prospectively used a diagnostic protocol including computed tomography of the ankle in the subsequent 23 patients. We determined the association between the two injuries and evaluated the ability of a new protocol to improve management of these associated fractures. Occult posterior malleolus fractures associated with distal spiral tibia fractures often are underrecognized and the morbidity of a missed posterior malleolus injury can be substantial. Associations between fracture patterns are important and can ensure proper diagnosis and guide treatment.
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