Posterior Malleolus Fracture

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The ankle is one of the most versatile joint complexes in the body. It is specifically built for weight bearing, mobility, adaptability, and stability. The foot and ankle allow us the ability to walk, stand, and serve as our connection to the ground. The ankle must be able to withstand the stress of body weight and also be able to adapt to and react quickly to changes in the environment and walking surface.

A fracture is a break, typically in a bone. If the broken bone punctures the skin, it is then called an open or compound fracture. Fractures often occur due to car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause the weakening of the bones. Overuse can also cause stress fractures, which are very small cracks in the bone.

A posterior malleolus fracture is a break that occurs at the back of the tibia at the level of the ankle joint. The posterior malleolus fracture isn’t common; however, it does occur in some cases. It may be difficult to manage this type of fracture, as the pattern of injury is often irregular and may be associated with other fractures as well. Also, considering the location and thin skin fold over it, a posterior malleolus fracture can easily damage the skin and result in an open fracture.

A posterior malleolus fracture rarely occurs as a single fracture and is mostly a part of trimalleolar fracture, in which the other two malleolus are also injured and may also have other ligament and soft tissue injuries. If there are multiple cracks or associated injuries, a posterior malleolus fracture may be much more difficult to treat.

Fortunately, most cases of posterior malleolus fractures do not require surgery (with an average recovery of at least 6 weeks), however, there is a medical grading depending on the severity that may need surgical treatment if you reach the third stage of a posterior malleolus fracture. The three grades are described below:

  • Grade 1 ankle fracture – A first graded fracture involves small cracks which may not be visible in X-rays. The bone remains intact and no displacement occurs.
  • Grade 2 ankle fracture – A grade 2 may involve a slight displacement and a larger part of the bone may have been damaged.
  • Grade 3 ankle fracture – The bone is completely broken into multiple pieces and is largely displaced. Such injuries are serious and are accompanied by damage to the soft tissues as well as ligaments.

Causes & Symptoms of a Posterior Malleolus Fracture

It is commonly known that isolated posterior malleolus fractures are quite rare and they’re most likely seen with other ankle injuries. The most common causes linked to this condition include:

  • Twisting of the ankle joint
  • Falls
  • Accidents
  • Injuries to the leg including sports injuries.

Sports that involve sudden twisting and turning, which can injure the ankle are one of the commonest causes of fractures to the posterior malleolus. Rolling that results from irregular or improper placing of the foot or landing on an uneven surface too can lead to posterior malleolus fractures. Additionally, some of the causes of the condition include a direct blow to the ankle or sudden, forceful impact on the ankle, as during vehicular accidents.

Other certain symptoms of posterior malleolus fractures include:

  • Pain – Feeling pain is the first symptom you will feel after experiencing a fracture at the injured site. This can extend from the foot to the entire knee if left untreated.
  • Swelling – There may be swelling which can occur along the length of the leg or may be more localized.
  • Blisters – Blisters may occur over the fracture site of the ankle joint. A blister is a painful skin condition where fluid fills a space between layers of skin. Therefore, these should be promptly treated by a foot specialist.
  • Change in appearance – You may notice a significant change in your ankle appearance, which is a sign of deformity.
  • Bruising – Bruising can develop soon after the injury. In most cases, redness will be present alongside the bruising of the posterior malleolus.

Who gets a Posterior Malleolus Fracture?

Risk factors that are associated with posterior malleolus fractures are similar to every other fracture, especially in the lower leg. Some of the most common are listed below:


Vehicle accident

Vehicle / motorbike accidents resulting in head-on collisions can cause an inward impact on the front end of the car. The left foot resting on the floor or right foot on the accelerator gets impacted and jammed which may result in a forceful rotation, hyper-flex, or hyper-extended ankle joint. Certain joint movements during the collision may cause the posterior malleolus to fracture.


Osteoporosis is a condition that results in a gradual decrease concentration of calcium. Overuse of the ankle joint or over-twist of the foot and ankle can cause a fracture of your posterior malleolus.


Oftentimes, repeated injuries to the soft tissues, ligament tear, or weakening of the supporting structures in elderly people or those with joint problems too can result in posterior malleolus fracture.

Occupation laborers

Some of the causes of a posterior malleolus fracture are also related to a direct blow to the back of the ankle joint while at work by moving objects or operating certain machinery.

Sports activity

Sports that involve repetitive twisting and turning of the lower leg and foot can cause injury of the ankle joint that may result in a posterior malleolus fracture. Some of these sports activities include soccer, tennis, cross-country, skiing, and martial arts.

How Does a a Posterior Malleolus Fracture Affect You? How Serious is it?

A few possible complications of surgery following a posterior malleolus fracture include the risk of infections and delayed healing. Another severe risk of posterior malleolus fracture is cartilage damage, which increases the risk of ankle arthritis.

These certain complications may lead to the requirement of additional treatment, as the wound healing can be slow in some cases. However, with accurate and timely treatment and effective management, the complications can be greatly reduced and proper healing can be expected.

Recommended Treatment & Rehabilitation for a Posterior Malleolus Fracture

A diagnosis for posterior malleolus fracture can be made based on a complete medical history, physical examination, and imaging tests. The history often reveals an accident, fall, or sports injury, as the complaints begin soon following the injury. Examination of the ankle joint reveals pain, tenderness, and swelling, based on which a possibility of multiple fractures and soft tissue injury can be assessed.

In some cases, if there is pain and tenderness located at the medial and lateral malleolus or if you are unable to walk due to severe ankle pain and swelling, a fracture is suspected and an X-ray is advisable. X-ray is ordered to confirm a break in the bone; in these cases, it could be posterior and sometimes even medial and lateral malleolus.

An X-ray also gives an idea about the type and severity of posterior malleolus fracture. If other soft tissue damage, ligament injuries, or other fractures are suspected, additional scans like computed tomography (CT) and magnetic resonance imaging (MRI) scans may be needed.

After a diagnosis is done, physiotherapy may be further advised. A physiotherapist can help treat a posterior malleolus fracture after it has been treated by a physician. After the bone is healed, your physiotherapist can help you regain your strength, motion, balance, and sports skills.

After your leg is placed in a cast or cast boot, your therapist will teach you how to walk without bearing weight on the injured ankle, using crutches or a walker. Therefore, some of these physiotherapy treatments will include:


Reducing swelling

Swelling is commonly the first sign after a posterior malleolus fracture. Treatment may include gentle massage, the use of a compression wrap, ice, or heat, and elevating the affected ankle when at rest.


Walking instruction

Your physiotherapist will help you begin to put some of your weight on the injured leg, gradually progressing to full weight.


Gait training

Your physiotherapist will offer specific instruction and exercises to restore a normal walking pattern. The focus will be on how your foot and ankle move, and the timing of your steps.


Restoring your ankle mobility

Your physiotherapist may use manual therapy to gently move your foot and ankle joints and surrounding tissues to reduce stiffness, and increase the ankle’s bending range of motion.


Returning to your regular activities

As you regain strength and flexibility, your physiotherapist will provide further training specific to your daily activities.


During your physiotherapy session, your therapist will design an exercise plan for you to begin after the cast has been successfully removed to help you strengthen and regain motion in your fractured posterior malleolus. The following exercises include:


Calf stretch

Sit with your affected leg straight and supported on the floor. Your other leg should be bent, with the foot flat on the floor. Next, place a towel around your affected foot just under the toes. Hold one end of the towel in each hand, with your hands above your knees. Pull back gently with the towel so that your foot stretches toward you. Hold the position for 15-30 seconds, then repeat 2-4 times a day.


Ankle dorsiflexion

Sit with your affected leg straight and supported on the floor. Your other leg should be bent, with the foot flat on the floor. Keeping your affected leg straight, gently flex your foot back toward your body so your toes point upward. Then slowly relax your foot to the starting position. Repeat this method 8-12 times a day.


Resisted ankle inversion

Sit on the floor with your good leg crossed over your other leg. Hold both ends of an exercise band and loop the band around the inside of your affected foot. Then press your good foot against the band. Keeping your legs crossed, slowly push your affected foot against the band so that the foot moves away from your good foot. Slowly relax, then repeat 8-12 times a day.


Resisted ankle eversion

Sit on the floor with your legs straight. Then, hold both ends of an exercise band and loop the band around the outside of your affected foot. Next, press your good foot against the band. Keeping your leg straight, slowly push your affected foot outward against the band and away from your good foot without letting your leg. Repeat this exercise 8-12 times a day.

Alternative & Homeopathic Treatment for a Posterior Malleolus Fracture

Several home remedies include the use of Epsom salt or simply resting your injured ankle. Some of these homeopathic treatments include the following:

  • Epsom salt – You can soak your injured ankle in a warm bath with Epsom salt after a few days of injury. Epsom salt may help soothe sore muscles and connective tissues, and it may help with joint stiffness.
  • Ice application – Apply ice to the ankle several times a day to help reduce pain and swelling.
  • Rest – It is recommended to not carry heavy items or play sports for a few days or weeks after you have dislocated your ankle in order to reduce further pain.
  • Compression – Apply an elastic compression bandage to help limit swelling.

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