A radiological sign (which we are calling the 'tongues of flame' sign) in irreducible trimalleolar fractures of the ankle.

BACKGROUND

The irreducible trimalleolar fracture case we describe is different from the Bosworth fracture, defined as a fixed posterior fracture-dislocation of the distal part of the fibula, in which the proximal fibular shaft fragment locks behind posterior tibial tubercle. This fracture is frequently irreducible by closed means as well.

METHODS

We describe a rare case of trimalleolar fracture/dislocation that cannot be reduced by closed means, and review the relevant literature.

RESULTS

The peroneal tendons were entrapped in a triangle between a postero-lateral displaced distal fibular fragment and a lateral displaced posterior malleolar (PM) fragment, and a proximal fragment of a Weber B fibular fracture. Intra-operative findings have proved that as soon as the peroneal tendons are disengaged from the triangle, the PM and fibular fractures can be easily reduced under direct vision (surgery). After the review of another 50 trimalleolar ankle fractures we describe a new radiographic sign, seen in the lateral radiographic view, with bony spikes from the distal fibular fragment posterior to the PM fragment, which we are calling the 'tongues of flame' sign. This feature was not noted on the radiographs of the other 50 trimalleolar fracture cases seen in our hospital.

CONCLUSION

The presence of this 'tongues of flame' sign should alert the treating surgeon to a possible irreducible ankle fracture/dislocation, which may need urgent attention for surgical management.