Modified 3D-Controlled Inside-Out Compression Screw Fixation Technique in Posterior Malleolar Fractures: A Narrative Review and Case Report

Fractures of the posterior malleolus are key determinants of ankle stability and long-term functional outcome in complex ankle injuries. The posterolateral rim fragment represents a bony avulsion of the posterior syndesmotic complex. Anatomical reduction of this fragment restores the fibular incisura, posterior tibiotalar stability, and syndesmotic integrity. Based on a geriatric case of a trimalleolar ankle fracture with a Bartoníček type 2 posterior malleolar component, this review describes a modified minimally invasive inside-out fixation technique performed under intraoperative three-dimensional imaging. The posterior malleolar fragment was stabilized using a posterior-to-anterior headless double-threaded compression screw. The medial malleolus was fixed with two parallel partially threaded cannulated cancellous screws, and the distal fibular fracture was stabilized using a reamed intramedullary locking nail. The surgical technique, potential complications, and postoperative management are described in detail. This approach combines the biomechanical advantages of direct posterior malleolar fixation with minimal soft-tissue disruption, providing a stable and reliable construct for the treatment of complex ankle fractures, particularly in geriatric patients and in those with compromised soft-tissue conditions.