Posterior Malleolar Fractures: Reappraising Fixation Thresholds and Functional Outcomes- A Narrative Review
Dr. Jeff Walter Rajadurai OR*
Associate Professor & Unit III Chief, Department of Orthopaedics, Madha Medical College & Research Institute, Chennai, India.
*Corresponding Author: Dr. Jeff Walter Rajadurai OR, Associate Professor & Unit III Chief, Department of Orthopaedics, Madha Medical College & Research Institute, Chennai, India.
https://doi.org/10.58624/SVOAOR.2026.06.024
Received: July 24, 2026
Published: August 24, 2026
Citation: Rajadurai JW. Posterior Malleolar Fractures: Reappraising Fixation Thresholds and Functional Outcomes- A Narrative Review. SVOA Orthopaedics 2026, 6:4, 173-188. doi: 10.58624/SVOAOR.2026.06.024
Abstract
Posterior malleolar fractures have been regarded as secondary parts of rotational ankle injuries and treatment decisions have been based mainly on the size of the posterior tibial fragment. Fixation was recommended for many years as only indicated when more than 25-30% of the tibial plafond was involved. This threshold is commonly used, but it was derived from early radiographic studies and was set before computed tomography (CT) became a routine tool. More recent evidence has challenged this traditional paradigm, showing that fragment morphology, syndesmotic integrity, articular congruity and fracture stability may be more clinically relevant than fragment size alone. Classification systems based on CT have improved the understanding of posterior malleolar fracture patterns and have facilitated more individualised surgical decision making. Furthermore, biomechanical and clinical studies have demonstrated the key role of the posterior malleolus in syndesmotic stability. Anatomical reduction and stable fixation may restore ankle biomechanics more effectively in some patients than isolated fixation with syndesmotic screws. This narrative review critically assesses the evolution of posterior malleolar fracture management, focusing on fixation thresholds, fracture morphology, operative techniques and functional outcomes. The review also deals with the current evidence on surgical approaches, fixation techniques, postoperative outcomes and the remaining controversies. The review merges anatomical principles and modern clinical evidence to suggest a shift in indications from fragment size to morphology-driven and stability-oriented treatment algorithms.
Keywords: Posterior malleolus; Ankle fracture; Syndesmosis; Computed tomography; Internal fixation; Functional outcome.