Clin Orthop Surg.  2025 Jun;17(3):523-529. 10.4055/cios24432.

Posterior Inferior Tibiofibular Ligament Periosteal Sleeve Avulsion: New Classification for Posterior Malleolar Fracture of the Ankle

• Kim SH
• Kim JH
• Choi SW
• Lee YK

• KMID: 2568334
• DOI: http://doi.org/10.4055/cios24432

Abstract

Background
Not reducing the posterior malleolar fragment could have an impact on the alignment and stability of syndesmosis since the posterior inferior tibiofibular ligament (PITFL) originates at the posterior malleolar fragment. Given that these alignment and stability changes may contribute to discomfort and pain, further research may be required. We think that our new classification method will be able to help improve understanding of treatment methods for posterior malleolar fractures.
Methods
We retrospectively analyzed 206 patients who underwent surgeries for ankle fractures in our orthopedic clinic between April 2014 and December 2022 and were verified to have posterior malleolar fractures in plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI). We performed a probing test to determine whether syndesmosis was stable.
Results
We were able to classify the 206 cases into the following 5 types: type 1 (31 cases, 15.0%), extraincisural fragment with an intact fibular notch; type 2 (98 cases, 47.5%), posterolateral fragment extending into the fibular notch; type 3 (37 cases, 17.9%), posteromedial 2-part fragment involving the medial malleolus; type 4 (19 cases, 9.2%), large posterolateral triangular fragment; and type 5 (21 cases, 10.1%), shell-like PITFL avulsion (< 2 mm) in a CT axial view or PITFL periosteal sleeve avulsion (PITPSA) in arthroscopic or MRI findings.
Conclusions
This new system that adds the PITPSA type for the classification of posterior malleolar fractures may be a useful approach to managing these injuries and may aid in treatment decision-making. It could be important to consider ligament surgery when treating PITPSA.

Keyword

Posterior malleolar fracture; Posterior inferior tibiofibular ligament avulsion fracture; Ankle stability; Arthroscopy