Jike Lu1, Masumi Maruo Holledge2, Jac Trappel3, Mehul Mayank4. 1. Department of Orthopaedic Surgery, Taree Hospital, NSW, Australia; Beijing United Family Hospital, 2 Jiangtai Lu, Chaoyang District, Beijing, 100015, China. Electronic address: 13911095602@163.com. 2. Beijing United Family Hospital, 2 Jiangtai Lu, Chaoyang District, Beijing, 100015, China. Electronic address: masumi.maruo@gmail.com. 3. School of Medicine, University of Newcastle, Australia. 4. Department of Orthopaedic Surgery, John Hunter Hospital, Newcastle, NSW, Australia.
Abstract
BACKGROUND: The irreducible trimalleolar fracture case we describe is different from the Bosworth fracture, defined as a fixed posterior fracture-dislocation of the distal part of the fibula, in which the proximal fibular shaft fragment locks behind posterior tibial tubercle. This fracture is frequently irreducible by closed means as well. METHODS: We describe a rare case of trimalleolar fracture/dislocation that cannot be reduced by closed means, and review the relevant literature. RESULTS: The peroneal tendons were entrapped in a triangle between a postero-lateral displaced distal fibular fragment and a lateral displaced posterior malleolar (PM) fragment, and a proximal fragment of a Weber B fibular fracture. Intra-operative findings have proved that as soon as the peroneal tendons are disengaged from the triangle, the PM and fibular fractures can be easily reduced under direct vision (surgery). After the review of another 50 trimalleolar ankle fractures we describe a new radiographic sign, seen in the lateral radiographic view, with bony spikes from the distal fibular fragment posterior to the PM fragment, which we are calling the 'tongues of flame' sign. This feature was not noted on the radiographs of the other 50 trimalleolar fracture cases seen in our hospital. CONCLUSION: The presence of this 'tongues of flame' sign should alert the treating surgeon to a possible irreducible ankle fracture/dislocation, which may need urgent attention for surgical management.
BACKGROUND: The irreducible trimalleolar fracture case we describe is different from the Bosworth fracture, defined as a fixed posterior fracture-dislocation of the distal part of the fibula, in which the proximal fibular shaft fragment locks behind posterior tibial tubercle. This fracture is frequently irreducible by closed means as well. METHODS: We describe a rare case of trimalleolar fracture/dislocation that cannot be reduced by closed means, and review the relevant literature. RESULTS: The peroneal tendons were entrapped in a triangle between a postero-lateral displaced distal fibular fragment and a lateral displaced posterior malleolar (PM) fragment, and a proximal fragment of a Weber B fibular fracture. Intra-operative findings have proved that as soon as the peroneal tendons are disengaged from the triangle, the PM and fibular fractures can be easily reduced under direct vision (surgery). After the review of another 50 trimalleolar ankle fractures we describe a new radiographic sign, seen in the lateral radiographic view, with bony spikes from the distal fibular fragment posterior to the PM fragment, which we are calling the 'tongues of flame' sign. This feature was not noted on the radiographs of the other 50 trimalleolar fracture cases seen in our hospital. CONCLUSION: The presence of this 'tongues of flame' sign should alert the treating surgeon to a possible irreducible ankle fracture/dislocation, which may need urgent attention for surgical management.