The risk of violating the posterior malleolar fracture when nailing the ipsilateral concomitant spiral distal tibial fracture

Abstract

Background: For a distal tibial spiral fracture combined with a non-displaced posterior malleolar fragment (PMF), we proposed a hypothesis that the treating surgeon could assess the size of the PMF to determine the need for stabilizing that structure first before rodding the tibia.

Materials and methods: Fifty 3-D models (22 females) of combined distal tibial and posterior malleolar fractures from one trauma center were reconstructed. In each case, a virtual tibial intramedullary nail (vIM nail) with three distal anteroposterior (AP) locking screws (S₁₃, S₁₅ and S₃₇, the number indicating the distance from the screw to the nail tip) were inserted into the center of the tibial canal and ended on top of the distal tibial physeal scar. Contact between the screws and the PMF was defined as causing PMF displacement. The relationship between PMF secondary displacement and traumatic anatomic factors (the fragment area and height of the PMF) was explored. Then, the parameters were justified by analyzing intraoperative radiographs of 35 cases treated by nail with single locking screw (S₁₅) design.

Results: In the analog experiment, multiple logistic regression analysis revealed that the height of the PMF could confidently predict the risk of fragment displacement (S₁₃: odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.32; S₁₅: OR 1.15, 95% CI 1.05-1.27). Regarding the height of the PMF, the receiver operating characteristic established a cut-off value of 31.2 mm for preliminary fixation of the fragment with 88.89% sensitivity and 88.89% specificity. In the operation group the nail stopped on the top of distal tibial physeal scar, no PMF secondary displacement occurred when the PMF height was less than 31.2 mm. However, the incidence of secondary displacement was 93.33% when the height of the PMF exceeded 31.2 mm.

Conclusion: When the distal tibial physeal scare was set as the limit of nail insertion depth, the height of the PMF could be used as a reliable reference predicting the risk of PMF secondary displacement caused by distal anteroposterior locking screw.

Keywords: Ankle fracture; Intramedullary nail; Morphological measurement; Tibial fracture.

Fig. 1

There are four types of Bartoníček’s classification scheme: a (type 1): extraincisural fragment with an intact fibular notch; b (type 2): posterolateral fragment extending into the fibular notch; c (type 3): posteromedial two-part fragment involving the medial malleolus; d (type 4): large posterolateral triangular fragment (involving more than one-third of the notch)

Fig. 2

a “Line a” is the projection line of the centers of the talar dome. b After the central sagittal plane (CSP) is determined, on this plane the tIN and three AP locking screws (S13, S15 and S37) are simulated. The relationship between AP locking screws and the PMF is demonstrated. c Measurements on reconstructed 3D model: the fragment height (FH) and the minimal distance from distal AP locking screw tip to the PMF (DSF). d Measurements on axial scan: minimal distance from the nail tip to the PMF (DNF)

Fig. 3

a Demonstrating a non-displaced PMF before intramedullary nail insertion. b The penetration of distal tibial physeal scar from nail tip resulted in a secondary displacement of the PMF from distal AP locking screw