There is widespread consensus that unstable ankle fractures require operative management to restore stability to the ankle joint and reduce the risk of post-traumatic arthritis. However, indications for reduction and fixation of the posterior malleolus component of these injuries remain controversial.

A 2011 survey of orthopaedic surgeons demonstrated wide variability in management practices for posterior malleolus fractures. While fragment size was determined to be an important feature, “stability and other factors” were cited more frequently as the indication for reduction and fixation [1]. Many different surgical indications have been proposed over the last century. The origins of these indications are not well known, nor is the evidence upon which they are based. Thus, this review aimed to identify the origin of the surgical indications for posterior malleolus fractures and to trace the evolution in management strategies over time.