INTRODUCTION The posterior malleolus (PM) is affected in around the 40% of ankle fractures. Anatomical reduction of the articular surface and fibular notch are essential for ankle stability and functional outcomes. These facts justify the increasing interest in the surgical treatment of PM in ankle fractures. Within this context, pre-operative computed tomography (CT) images and posterior approaches to the ankle play a crucial role. The aim of this paper is to make an accurate description of the literature and describe, according to authors' experience, the best surgical approach to the PM based on the CT findings while assessing their advantages and disadvantages. METHODS The fracture pattern of PM is classified according to Haraguchi or Bartoníček classification, both based on pre-operative CT scan images. The posterolateral (PLA) and posteromedial (PMA) approaches to the ankle and their corresponding modifications are described. We propose a decision-making algorithm for posterior malleolus fractures to facilitate treatment selection. RESULTS Posterolateral approach should be the election for Haraguchi I or III and Bartoníček 1, 2, or 4 fractures. Percutaneous PLA might be adequate in Haraguchi I and Bartoníček 1 to improve syndesmotic stability. In PL approaches, the fibula fracture may be addressed and fixed with a posterolateral plate or through a subcutaneous window that allows lateral reduction and fixation. Posteromedial approach should be the election for Haraguchi II and Bartoníček 3 fractures. A modified PMA might be the election to reduce and fix any fragment dependent on the anterior inferior tibiofibular ligament (AITFL). The modified PMA is performed in a supine position and allows us to check the articular reduction under direct vision. Both PMA are associated with a lateral fibular approach. CONCLUSION To address the posterior malleolus when treating ankle fractures, surgeons should choose the most adequate approach based on the fracture pattern and their own experience. Anatomical reduction and stable fixation are critical to improve outcomes.

中文翻译：

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如何解决踝部骨折中的后踝？基于计算机断层扫描结果的决策模型。

简介后踝（PM）在40％的踝部骨折中受到影响。关节面和腓骨切迹的解剖复位对于踝关节稳定性和功能预后至关重要。这些事实证明了对踝部骨折中PM外科治疗的兴趣日益增加。在这种情况下，术前计算机断层扫描（CT）图像和后踝入路起着至关重要的作用。本文的目的是对文献进行准确的描述，并根据作者的经验，根据CT表现描述最佳的PM手术方法，同时评估其优缺点。方法根据术前CT扫描图像，根据原口或Bartoníček分类对PM的骨折类型进行分类。描述了踝关节的后外侧（PLA）和后内侧（PMA）方法及其相应的修改。我们提出后踝骨折的决策算法，以方便治疗选择。结果应采用后外侧入路治疗Haraguchi I或III和Bartoníček1、2或4骨折。在Haraguchi I和Bartoníček1中，经皮PLA可能足以改善结缔组织的稳定性。在PL方法中，腓骨骨折可通过后外侧板或通过允许侧向复位和固定的皮下窗口进行处理和固定。后原位入路应选择Haraguchi II和Bartoníček3骨折。修改后的PMA可能是减少和修复任何依赖于前下胫腓韧带（AITFL）的碎片的选择。改良的PMA在仰卧位进行，使我们能够检查直视下的关节复位情况。两种PMA均与腓骨外侧入路相关。结论为了解决踝部骨折时的后踝骨折，外科医生应根据骨折类型和自身经验选择最合适的方法。解剖复位和稳定固定对于改善预后至关重要。