What is your diagnosis?

The patient is diagnosed with an isolated posterior malleolar fracture. These generally arise from a rotational force.

• Pearl: Be aware of other fractures and syndesmotic injury as posterior malleolar fractures are often associated with more complex injuries. Only 1–4% are isolated posterior malleolar fractures [1].

• Pearl: An isolated posterior malleolar fracture is also known as a Volkmann’s fracture or Earle’s fracture [2].

How is it diagnosed?

Posterior malleolar fractures can be easily missed. X-ray images should be used for diagnosis, with special attention to the lateral view. CT scan can be used for indeterminate cases and to better evaluate the fracture fragment [2].

• Pearl: Weight bearing x-rays can be helpful in assessing concomitant syndesmotic injuries and medial mortise widening. 

Image 2: Original image provided by Justine Ko, MD 

with the red arrow pointing toward the fracture line.

What is your management in the ED? What is your disposition?

Patients should be placed in a posterior mold splint with the ankle in neutral position and be made non-weight bearing. Close follow up with orthopedics is important as many of these injuries may require surgery. 

• Pearl: Surgery indications are still up for debate. Size of the fragment and percentage of articular surface involvement contributes to this decision [3].