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2023 Journal CME: Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes?

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Accreditation Statement: The Orthopaedic Trauma Association (OTA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation:  OTA designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Learning Objectives

After completing this activity, learners will be able to:

  1. Determine the differences in postoperative functional outcomes, patient reported outcomes, time to union, and complications between indirect and direct fixation of the posterior malleolus in the setting of trimalleolar ankle fractures.
  2. Describe the impact of prolonged tourniquet use on the final functional outcome patient reported measure following surgery. 
  3. Discuss the significant impact of an open fracture on reported pain scores at 2-years following surgery.


  • Author: Richard Yoon, MD and David N. Keller, DO

Original release date: 3/31/2023

Expiration date: 3/31/2024

Estimated time to complete activity: 1 hour

Statement of Need/Description/or Summary of Gap Analysis

Practice gap lies in the outcome differences between indirect and direct fixation of posterior malleolar fractures in the setting of trimalleolar ankle fractures. Historically, indirect reductions were preferred due to potential wound complications associated with direct approach and fixation1 (1). However, with modern techniques, these complications have significantly decreased2 (2). Understanding the nuances and differences between each fixation strategy can be applied to each individual patient/fracture pattern to maximize outcomes. 

1. Gardner MJ, Streubel PN, McCormick JJ, et al. Surgeon Practices regarding Operative Treatment of Posterior Malleolus Fractures. Foot Ankle Int. 2011;32:385–393.
2. Shi H, Xiong J, Chen Y, et al. Comparison of the direct and indirect reduction techniques during the surgical management of posterior malleolar fractures. BMC Musculoskelet Disord. 2017;18:109.

Instructional Format: This Orthopaedic Trauma Association International Journal CME activity consists of a journal article, a quiz, and an evaluation.

Method of Participation: There are no fees for members to participate in this activity. Non-members must pay $30. This online activity consists of an article, a self-assessment exam, and an evaluation. To receive AMA PRA Category 1 Credit™ credit, participants must read the journal article, successfully complete the post-test quiz, and achieve a minimum score of 75% on the quiz. The quiz includes 4 multiple choice questions. Learners will be asked to read each question, select an answer, and review the section of the article where the answer is found. Learners will be able to review the content and repeat the quiz as many times as needed. Upon achieving a score of 75% or higher, learners will be asked to complete a post-activity evaluation. A certificate of credit or participation will be available upon successful submission of the post-activity evaluation.


The Orthopaedic Trauma Association has implemented a policy to comply with the current Accreditation Council for Continuing Medical Education (ACCME) Standards for Integrity and Independence in Accredited Continuing Education requiring mitigation of all conflicts of interest. Faculty declaring a relevant commercial interest must be identified in the activity syllabus and/or program.

In accordance with disclosure policies of OTA and the ACCME, every effort has been made to ensure all CME activities are balanced, independent, objective, and scientifically rigorous. These policies include complying with ACCME’s Standards for Integrity and Independence in Accredited Continuing Education and mitigating all relevant conflicts of interest for all individuals in control of content.  

All of the relevant financial relationships listed for these individuals have been mitigated

All disclosures are available on the "Disclosure" tab.

Disclaimer: The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by the OTA.  In no event will the OTA be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

Commercial Support: There is no commercial support for this activity


Read the CME Article
Open to download resource.
Open to download resource. Please read the OTAI Journal CME Article by downloading the attached PDF.
4 Questions  |  Unlimited attempts  |  3/4 points to pass
4 Questions  |  Unlimited attempts  |  3/4 points to pass Please complete the following multiple-choice quiz. You must achieve 75% or higher to pass.
8 Questions
8 Questions Please complete the activity evaluation to claim CME credit for this course.
CME Certificate
Up to 1.00 medical credits available  |  Certificate available
Up to 1.00 medical credits available  |  Certificate available