The malleolar fractures are not included in the statistical analysis of the 54.280 surgically treated fractures from which this atlas has been compiled. This is because of the difficult radiographic assesment of the ligamentous lesions that are quite frequently associated to these fractures and that significantly influence their prognosis, severity and, therefore, their classification. Since these are the most common fractures, along with those of segment 23, we have reviewed a series of 300 consecutive cases documented at the M.E. Müller Foundation of Barcelona. This appendix has been compiled from the findings.

Because of their anatomic characteristics, the malleolar fractures are the exception to the rule of dividing each long bone into three bony segments. They are the segment 44- of the tibial bone.

As it is for the other segments, the fracture types are divided into A, B and C, but they are defined by the level of the lesion of the lateral malleolus in relation to the ligamentous complex of the syndesmosis. In type A, the lateral lesion is located below the syndesmosis (infrasyndesmotic). In type B, the fibular fracture is in between the anterior and posterior ligaments that form the syndesmosis (transsyndesmotic). In type C, the lateral lesion is proximal to the syndesmosis (suprasyndesmotic). The classification of the groups is based upon the characteristics of the fibular fracture, to which the associated lesions of the medial and posterior malleoli are considered for the types A and B, while for the C type it is based upon the characteristics of the suprasyndesmotic fracture of the fibula. The more complex subgroup classification will usually need consultation to the Classification book.

The isolated lesion of the posterior articular rim (posterior malleolus or of Volkmann) is considered a tibial pilon fracture. The isolated lesions of the medial malleolus (without involvement of the fibula) are also considered fractures of the segment 43-.

The treatment is systematized in the “small fragment” category. It must obtain the anatomic reduction of the ankle mortice and the stability of both, the collateral ligaments and the syndesmosis. To this purpose it is essential to make an adequate diagnosis and treatment of the pull-off fractures of the tubercles of Chaput and Le Fort. The short and medium term results are quite good but, in the long term, there usually is a clinical-radiographic dissociation, sometimes spectacular, as we have been able to verify in a control study with a follow-up of more than 5 years.