Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems

Elena Mueller; Holger Kleinertz; Marlon Tessarzyk; Stefan Rammelt; Jan Bartoníček; Karl-Heinz Frosch; Alexej Barg; Carsten Schlickewei

doi:10.1007/s00068-022-02119-2

Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems

Eur J Trauma Emerg Surg. 2023 Apr;49(2):851-858. doi: 10.1007/s00068-022-02119-2. Epub 2022 Nov 4.

Authors

Elena Mueller^#¹, Holger Kleinertz^#¹, Marlon Tessarzyk¹, Stefan Rammelt², Jan Bartoníček³, Karl-Heinz Frosch^{1

4}, Alexej Barg^#^{1

4}, Carsten Schlickewei⁵

Affiliations

¹ Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
² University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany.
³ Department of Orthopaedics, First Faculty of Medicine, Charles University, Central Military Hospital Prague, Prague, Czech Republic.
⁴ Department of Trauma Surgery, Orthopaedics, and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany.
⁵ Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. c.schlickewei@uke.de.

^# Contributed equally.

Abstract

Introduction: Complex ankle fractures frequently include the posterior malleolus (PM). Despite advances in diagnostic and treatment strategies, PM fracture involvement still predisposes to worse outcomes. While not incorporated into the most common PM fracture classifications, the presence of an intercalary fragment (ICF) complicates treatment. This study aims to describe the incidence, morphology, and location of ICFs in PM fractures.

Materials and methods: A total of 135 patients with a mean age of 54.4 (SD ± 18.9) years and PM fractures were analyzed for the presence of an ICF. Patients with an ICF were compared to those without in terms of age, gender, and treatment received. Characteristics of the ICFs in terms of location and size were assessed. Furthermore, the presence of an ICF in relation to the PM fracture classification according to Haraguchi et al., Bartoníček/Rammelt et al., and Mason et al. was investigated.

Results: ICFs presented in 55 (41%) of the 135 patients. Patients with an ICF were younger, and the PM was more often operatively treated when compared to patients without an ICF. A posterolateral approach was used significantly more often in patients with an ICF. Almost all ICFs were found in the posterolateral (58%) and posterocentral (35%) regions. The majority of fragments were found in Bartoníček/Rammelt type 2 fractures, the most common fracture type. Bartoníček/Rammelt type 3 fractures had the highest relative frequency of ICFs.

Conclusion: ICFs are frequently found in PM fractures; however, they are not incorporated into any of the common classifications. They are generally found in younger patients and associated with more complex PM fractures. As they can complicate reduction of the main fragment and may require direct exposure to restore joint congruency, ICFs should be considered in PM fracture classifications. Due to their location, the majority of ICFs are able to be accessed using a posterolateral approach.

Keywords: Ankle fracture; Bartoníček/Rammelt; Intercalary fragment; Posterior malleolar fracture.

MeSH terms

Ankle Fractures* / diagnostic imaging
Ankle Fractures* / surgery
Fracture Fixation, Internal
Humans
Incidence
Middle Aged
Retrospective Studies
Tibia
Tomography, X-Ray Computed
Treatment Outcome