The posterior malleolus: Should it be fixed and why?

Posterior malleolar fractures in the setting of a rotational ankle injury are common. While operative fixation of the medial and lateral malleoli in unstable ankle fractures has become standard treatment, the indications for stabilization of the posterior malleolus has been more controversial. Many biomechanical studies have been performed, often with conflicting results. Many clinical studies also have been performed, yet no clear high-level evidence exists to guide treatment. We recommend operative fixation of the most posterior malleolar fractures to restore the position and integrity of the posterior ligaments, to ensure reduction of the syndesmosis and to recreate the posterior buttress for ankle containment.