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Fracture, Volkmann: Posterolateral Tibiofibular Ligament Avulsion

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Fracture, Volkmann: Posterolateral Tibiofibular Ligament Avulsion
Matt DesJardins
Basics
Pediatric Considerations
  • Volkmann fracture is a rare injury in children <14 yrs of age, given the relative weak physis of the tibia.
  • Salter-Harris fractures occur during external rotation and abduction injuries, which only occasionally involve the posterior tubercle. The fracture fragment usually is contiguous with the medial malleolar fragment.
  • The Lauge-Hansen (L-H)1, Danis-Weber, and Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen systems have been used to describe ankle injury patterns. The L-H system can aid in closed reduction maneuvers.
  • Volkmann fracture is classified by the L-H system as supination external rotation (SER) stage III, pronation external rotation (PER) stage IV, and pronation abduction (PA) stage II.
  • In SER injuries, anterior inferior talofibular ligament (AITFL) rupture and spiral fracture of the fibula precede Volkmann fracture.
  • In PER injuries, deltoid ligament rupture, medial malleolar fracture, AITFL disruption, and oblique fibular fracture may precede Volkmann fracture.
  • In PA injuries, deltoid ligament rupture or avulsion of the medial malleolus may occur first.
Description
  • Ankle fracture involving avulsion of the posterior lip of the tibia at its articular surface (Volkmann tubercle)
  • Fracture occurs via a force through the PITFL at its tibial attachment.
Epidemiology
  • Few data exist regarding incidence or prevalence of isolated posterior malleolar fracture.
  • Volkmann fracture generally occurs concurrently with other malleolar fractures, deltoid and syndesmotic membrane injuries.
  • Associated with spiral tibia fractures (2,3)
Etiology
  • Volkmann tubercle is part of the posterior aspect of the medial malleolus of the ankle, commonly referred to as the posterior malleolus.
  • The posterior malleolus extends from the fibular notch of the tibia to the medial malleolus.
  • The PITFL's attachment to the posterior malleolus resists posterior translation of the talus.
  • The PITFL is 1 of 4 syndesmotic ligaments that maintain integrity between the tibia and fibula. Also referred to as the posterior tibiofibular ligament.
Diagnosis
History
  • Ankle injury involving a Volkmann fracture is rarely subtle, given typical concomitant fractures and ligament tears.
  • A mechanism of injury involving external rotation or abduction and the presence of associated injuries should evoke suspicion.
  • Any floor or field sport, particularly those with contact, can result in posterior malleolar fracture.
  • Patients should be questioned for elapsed time since injury, mechanism, associated sounds such as “pops” or “cracks,” and weight-bearing ability.
Physical Exam
  • Emergent examination:
    • Should focus on neurovascular compromise secondary to joint dislocation or calf compartment syndrome and skin integrity
    • Doppler US should be used if pulses are nonpalpable, and a detailed sensorimotor examination of the foot should be done.
    • Concern for early compartment syndrome should prompt measurement of calf compartment pressures.
  • Nonemergent examination:
    • Systematic ankle, foot, leg, and knee examination should be performed.
    • Observation, palpation, and careful range of motion should be done, followed by stability testing.
    • Acute examination will reveal a painful, tender, and swollen ankle consistent with a moderate or severe injury.
    • Possible findings include an increased posterior drawer test, increased internal rotation, and, with associated syndesmotic instability, a positive squeeze and external rotation test.
Diagnostic Tests & Interpretation
Imaging
  • Anteroposterior, lateral, and mortise views are standard.
  • Lateral films generally show the posterior malleolar fracture, but do not reliably estimate the size of the avulsion or the articular surface involvement (4). Some authors recommend an external rotation lateral view (45–50 degrees) to estimate fragment size (5).
  • Standard views will diagnose associated injuries that are almost always present.
  • Stress radiographs are controversial and not routinely indicated.
  • If Volkmann fracture is seen on plain film evaluation, CT is recommended to elucidate the extent of articular involvement and size of the fragment, which are instrumental in determining treatment.
  • MRI reserved for evaluation of soft tissues and generally not indicated unless CT films are inadequate.

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Treatment
  • Closed reduction generally not indicated for definitive treatment
  • Closed reduction is indicated prior to definitive treatment if the neurovascular structures or skin are compromised.
  • Fracture of posterior malleolus usually is accompanied by fracture of lateral and/or medial malleoli, and involves significant articular surface or fibular displacement.
  • Small (<25% of distal tibia), nondisplaced, incomplete fractures can be considered for a short-leg walking cast with appropriate orthopedic consultation.
  • Use of a modified Jones compression dressing and posterior splint is important to reduce swelling, which when untreated, can increase risk of poor surgical outcome.
  • Compression dressing with frequent icing and elevation can allow for operative intervention in the 1st 2–3 days.
Additional Treatment
General Measures
  • Usually occurs with external rotation or abduction
  • Given that the PITFL is markedly stronger than the anterior inferior tibiofibular ligament (AITFL), the torsional/rotational forces rupture the AITFL but avulse the posterior tibial tubercle through an intact PITFL.
  • Complicated ankle fractures require immediate assessment of the neurovascular status of the foot.
  • If compromised, reduction of dislocation or deformity should be accomplished immediately by closed reduction using the L-H classification to reverse order of injury.
Ongoing Care
  • Controversy exists as to whether all posterior malleolar fractures need to be internally fixated (6).
  • Volkmann tubercle often reduces spontaneously with reduction of the fibula and/or medial malleolus.
  • Size of the fragment and its proportion of the articular surface are predominant factors in determining the need for internal fixation.
  • Most recommend internal fixation if 25–35% of the articular surface is fractured (4,6).
  • If factors such as displacement of malleoli, talar subluxation, plafond articular incongruity, or syndesmotic instability exist, internal fixation is recommended.
Prognosis
  • Posterior tubercle fractures adversely affect the prognosis of ankle fractures compared to single or bimalleolar fractures (7).
  • These fractures have an increased risk of joint dislocation and osteoarthritis.
  • Postoperative arthritis varies with the size of the fragment and amount of articular surface involvement, but those requiring internal fixation have ≥35% likelihood of osteoarthritis.
References
1. Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957–985.
2. Boraiah S, Gardner MJ, Helfet DL, et al. High association of posterior malleolus fractures with spiral distal tibial fractures. Clin Orthop Relat Res. 2008.
3. Hou Z, Zhang Q, Zhang Y, et al. A occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture. J Trauma. 2009;66:1385–1390.
4. Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88:1085–1092.
5. Ebraheim NA, Mekhail AO, Haman SP. External rotation-lateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int. 1999;20:379–383.
6. Clare MP. A rational approach to ankle fractures. Foot Ankle Clin. 2008;13:593–610.
7. Fitzpatrick DC, Otto JK, McKinley TO, et al. Kinematic and contact stress analysis of posterior malleolus fractures of the ankle. J Orthop Trauma. 2004;18:271–278.
Additional Reading
Mandracchia DM, Mandracchia VJ, Buddecke DE. Malleolar fractures of the ankle. A comprehensive review. Clin Podiatr Med Surg. 1999;16:679–723.
Michelson JD. Fractures about the ankle. J Bone Joint Surg. 1995;77A:142–152.
Stanitski CL. Pediatric and adolescent sports injuries. Clin Sport Med. 1997;16:613–633.
van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009;66:279–284.
Vander Griend RA, Savoie FH, Hughes JL. Fractures of the ankle. In: Rockwood CA Jr, Green DP, Bucholz RW, eds. Rockwood and Green's fractures in adults, vol. 2, 3rd ed. Philadelphia: JB Lippincott, 1991:1983–2039.
Vander Griend R, Michelson JD, Bone LB. Fractures of the ankle and the distal part of the tibia. Instr Course Lect. 1997;46:311–321.
Codes
ICD9
  • 824.0 Fracture of medial malleolus, closed
  • 824.8 Unspecified fracture of ankle, closed


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