Journal of Foot and Ankle Surgery (Asia Pacific)

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VOLUME 8 , ISSUE 4 ( October-December, 2021 ) > List of Articles

Symposium: Complex Injuries Around The Ankle

Quadrimalleolar Fractures of the Ankle: Think 360°—A Step-by-step Guide on Evaluation and Fixation

Joannas German, Arrondo Guillermo, Stefan Rammelt, Casola Leandro, Mizdraji Luciano

Keywords : Ankle fracture, Anterolateral approach, Complex ankle fractures, Modified posteromedial approach, Posterior malleolus, Posterolateral approach, Quadrimalleolar fractures, Syndesmosis injury

Citation Information : German J, Guillermo A, Rammelt S, Leandro C, Luciano M. Quadrimalleolar Fractures of the Ankle: Think 360°—A Step-by-step Guide on Evaluation and Fixation. J Foot Ankle Surg Asia-Pacific 2021; 8 (4):193-200.

DOI: 10.5005/jp-journals-10040-1199

License: CC BY-NC 4.0

Published Online: 20-10-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Trimalleolar fractures, which involve the medial malleolus, lateral malleolus, and posterior malleolus, have been traditionally associated with a less favorable prognosis in ankle fractures. Less frequently, the anterolateral tibial rim (“Tillaux-Chaput tubercle”) and anteromedial fibular rim (“Wagstaffe-LeFort fragment”) are fractured. Trimalleolar fractures with anterior fractures are named quadrimalleolar fractures. Only correct planning will lead us to a good result. A 360° view is needed to plan appropriate treatment for fractures including the anterior and posterior tibial rim. CT scanning is essential. The ankle is divided into four areas on the axial CT scan: (A) (posterior malleolus), (B) (medial malleolus), (C) (lateral malleolus), and (D) (anterior malleolus Chaput and/or Wagstaffe fragments). Depending on which malleolus is involved, different approaches and ways of fixing the fractures have been described. At the end of the procedure, after performing open reduction and internal fixation of all four malleoli, syndesmotic stability must be tested intraoperatively. Patients with complex malleolar fractures are kept with a walker boot for 15–21 days after surgery with sole contact (max. 20 kg), to avoid subsequent retraction and forced plantar flexion of the ankle. Early walking as tolerated with two crutches at week 4. In the fifth week, we are authorized to weight bear 50% (one crutch) and in the sixth week full weight-bearing. These periods are prolonged with osteoporosis, plafond impaction, or poor patient compliance.

  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691–697. DOI: 10.1016/j.injury.2006.04.130.
  2. De Vries JS, Wijgman AJ, Sierevelt IN, et al. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005;44(3):211–217. DOI: 10.1053/j.jfas.2005.02.002.
  3. Switaj PJ, Weatherford B, Fuchs D, et al. Evaluation of posterior malleolar fractures and the posterior pilon variant in operatively treated ankle fractures. Foot Ankle Int 2014;35(9):886–895. DOI: 10.1177/1071100714537630.
  4. Stufkens SAS, van den Bekerom MPJ, Kerkhoffs GMMJ, et al. Long-term outcome after 1822 operatively treated ankle fractures: a systematic review of the literature. Injury 2011;42(2):119–127. DOI: 10.1016/j.injury.2010.04.006.
  5. Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg 2021. DOI: 10.1007/s00402-021-03875-3.
  6. Tejwani NC, Pahk B, Egol KA. Effect of posterior malleolus fracture on outcome after unstable ankle fracture. J Trauma 2010;69(3):666–669. DOI: 10.1097/TA.0b013e3181e4f81e.
  7. Bartoníček J, Rammelt S, Tuček M. Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 2017;22(1):125–145. DOI: 10.1016/j.fcl.2016.09.009.
  8. Bartoníček J, Rammelt S, Kostlivý K, et al. Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg 2015;135(4):505–516. DOI: 10.1007/s00402-015-2171-4.
  9. Mason LW, Marlow WJ, Widnall J, et al. Pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. Foot Ankle Int 2017;38(11):1229–1235. DOI: 10.1177/1071100717719533.
  10. Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 2006;88(5):1085–1092. DOI: 10.2106/JBJS.E.00856.
  11. Rammelt S, Bartoníček J. Posterior malleolar fractures: a critical analysis review. JBJS Rev 2020;8(8):e19.00207. DOI: 10.2106/JBJS.RVW.19.00207.
  12. Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J 2017;99-B(11):1413–1419. DOI: 10.1302/0301-620X.99B11.BJJ-2017-1072.
  13. Rammelt S, Swords M, Dhillon MS, et al. Manual of fracture management foot and ankle. Stuttgart/New York: Thieme Publishers and Davos, AO Foundation; 2020.
  14. Baumbach SF, Herterich V, Damblemont A, et al. Open reduction and internal fixation of the posterior malleolus fragment frequently restores syndesmotic stability. Injury 2019;50(2):564–570. DOI: 10.1016/j.injury.2018.12.025.
  15. Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int 2018;39(1):99–104. DOI: 10.1177/1071100717735839.
  16. Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–171. DOI: 10.1097/01.blo.0000203489.21206.a9.
  17. Heim D, Niederhauser K, Simbrey N. The Volkmann dogma: a retrospective, long-term, single-center study. Eur J Trauma Emerg Surg 2010;36(6):515–519. DOI: 10.1007/s00068-010-0061-6.
  18. Chaput H. Les Fractures Malleolaires du Cou-de-pied et les Accidents du Travail. Masson et Cie; 1857. vol. 1907 p. 147. Available from:
  19. Tillaux P. Recherches cliniques et experimentales sur les fractures malleolaires, rapport par gosselin. Bull Acad Med 1872;21:817.
  20. Wagstaffe WW. An unusual form of fracture of the fibula. St Thomas Hosp Rep 1875;6:43.
  21. Le Fort L. Note sur une variete non-decrite de fracture verticale de la malleole externe par arrachement. Bull Gen Ther 1886;110:193–199.
  22. Van Laarhoven CJ, Oostvogel HJ, van der Werken C. Differentiated protocol for the conservative/surgical treatment of ankle fractures in adults. Ned Tijdschr Geneeskd 1996;140(47):2342–2349.
  23. Rammelt S, Bartoníček J, Schepers T, et al. Fixation of anterolateral distal tibial fractures: the anterior malleolus. Oper Orthop Traumatol 2021;33(2):125–138. DOI: 10.1007/s00064-021-00703-0.
  24. Rammelt S, Bartoníček J, Kroker L, et al. Surgical fixation of quadrimalleolar fractures of the ankle. J Orthop Trauma 2021;35(6):e216–e222. DOI: 10.1097/BOT.0000000000001915.
  25. Valach J. Kvadrimaleoárna zlomenina predkolenia. Rozhl Chir 1964;43:747–749.
  26. Arrondo GM, Joannas G. Complex ankle fractures: practical approach for surgical treatment. Foot Ankle Clin 2020;25(4):587–595. DOI: 10.1016/j.fcl.2020.08.002.
  27. Zhong S, Shen L, Zhao J, et al. Comparison of posteromedial versus posterolateral approach for posterior malleolus fixation in trimalleolar ankle fractures. Orthop Surg 2017;9(1):69–76. DOI: 10.1111/os.12308.
  28. Ferries JS, DeCoster TA, Firoozbakhsh KK, et al. Plain radiographic interpretation in trimalleolar ankle fractures poorly assesses posterior fragment size. J Orthop Trauma 1994;8(4):328–331. DOI: 10.1097/00005131-199408000-00009.
  29. Donohoe S, Kiran Alluri R, Ryan Hill J, et al. Impact of computed tomography on operative planning for ankle fractures involving the posterior malleolus. Foot Ankle Int 2017;38(12):1337–1342. DOI: 10.1177/1071100717731568.
  30. Kumar A, Mishra P, Tandon A, et al. Effect of CT on management plan in malleolar ankle fractures. Foot Ankle Int 2018;39(1):59–66. DOI: 10.1177/1071100717732746.
  31. Rammelt S, Boszczyk A. Computed tomography in the diagnosis and treatment of ankle fractures. JBJS Rev 2019;6(12):e7. DOI: 10.2106/JBJS.RVW.17.00209.
  32. Bouche PA, Gaujac N, Corsia S, et al. Ankle CT scan allows better management of posterior malleolus fractures than X-rays. Eur J Orthop Surg Traumatol 2021. DOI: 10.1007/s00590-021-03104-yOnline ahead of print.
  33. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I. Anatomical studies. Acta Orthop Scand 1979;50(2):217–223. DOI: 10.3109/17453677908989759.
  34. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 1994;10(5):558–560. DOI: 10.1016/s0749-8063(05)80014-3.
  35. Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 2015;41(6):601–614. DOI: 10.1007/s00068-014-0466-8.
  36. Lilyquist M, Shaw A, Latz K, et al. Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int 2016;37(8):882–890. DOI: 10.1177/1071100716643083.
  37. Park J-W, Kim S-K, Hong J-S, et al. Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma 2002;52(4):655–659. DOI: 10.1097/00005373-200204000-00007.
  38. Haraguchi N, Toga H, Shiba N, et al. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med 2007;35(7):1144–1152. DOI: 10.1177/0363546507299531.
  39. Meulenkamp B, Louati H, Morellato J, et al. Posterior malleolus exposure. OTA Int 2019;2(2):e021. DOI: 10.1097/OI9.0000000000000021 Available from:
  40. Gardner MJ, Streubel PN, McCormick JJ, et al. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int 2011;32(4):385–393. DOI: 10.3113/FAI.2011.0385.
  41. Palmanovich E, Brin YS, Laver L, et al. The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures. Int Orthop 2014;38(5):1051–1056. DOI: 10.1007/s00264-013-2224-7.
  42. Assal M, Dalmau-Pastor M, Ray A, et al. How to get to the distal posterior tibial malleolus? a cadaveric anatomic study defining the access corridors through 3 different approaches. J Orthop Trauma 2017;31(4):e127–e129. DOI: 10.1097/BOT.0000000000000774.
  43. Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: the effect of plate and screw position. Foot Ankle Int 2005;26(4):281–285. DOI: 10.1177/107110070502600403.
  44. Bartoniček J, Mittlmeier T, Rammelt S. Anatomie, biomechanik und pathomechanik des pilon tibiale. Fuß Sprunggel 2012;10(1):3–11. DOI: 10.1016/j.fuspru.2012.01.017 Available from:
  45. Birnie MFN, van Schilt KLJ, Sanders FRK, et al. Anterior inferior tibiofibular ligament avulsion fractures in operatively treated ankle fractures: a retrospective analysis. Arch Orthop Trauma Surg 2019;139(6):787–793. DOI: 10.1007/s00402-019-03138-2.
  46. Heim U, Pfeiffer KM. Internal Fixation of Small Fractures: Technique Recommended by the AO-ASIF Group. Springer Science & Business Media; 2012. p. 396. Available from:
  47. Vivtcharenko VY, Giarola I, Salgado F, et al. Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: a cadaveric study. Injury 2021;52(Suppl 3):S84–S88. DOI: 10.1016/j.injury.2021.02.017.
  48. Lehtola R, Leskelä HV, Flinkkilä T, et al. Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: a minimum 6-year follow-up of a randomised controlled trial. Injury 2021. S0020-1383(21)00588-X 10.1016/j.injury.2021. 06.025.
  49. Stoffel K, Wysocki D, Baddour E, et al. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 2009;91(11):2646–2652. DOI: 10.2106/JBJS.G.01537.
  50. Pakarinen H, Flinkkilä T, Ohtonen P, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am 2011;93(22):2057–2061. DOI: 10.2106/JBJS.J.01287.
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