Cotton fracture

This is an unstable fracture with considerable risk of significant ligamentous injury, and treatment is generally performed operatively.

Computed tomography is important for the operative planning by providing an elaborated view of the posterior malleolus

The operative threshold is variable. Indications for internal fixation may be gleaned by measuring the size of the fracture fragment as a percentage of the total articular surface on the lateral radiograph or sagittal CT; or post reduction articular steps >1 mm.

History of the Cotton fracture

1910 – Frederic Jay Cotton (1869-1939) in his textbook chapter on ‘Injuries at and about the ankle‘, outlines the mechanism and reduction of Pott fracture with posterior luxation and fracture

1915 – Cotton described 53 cases of bimalleolar fracture with posterior luxation and fracture of the distal posterior tibia; mechanism of causation; reduction and operative treatment. [JAMA. 1915;64:318–321.]

I have been talking about the lesion for years, until some of my house-officers at the City Hospital, wearied by long insistence, have come to refer to it as “Cotton’s fracture.”

The characteristic point of the fracture under consideration is backward dislocation with the splitting away of a wedge large or small from the back surface of the tibia at the joint – a wedge that is displaced backward with backward dislocation of the foot. This wedge carries the posterior tibio-astragaloid ligaments; foot and tibial fragment move together, up and backward…the posterior tibial fragment is separate, though associated with fracture of both malleoli.

Cotton 1915

Associated Persons

• Frederic Jay Cotton (1869-1939)
• Percivall Pott (1714-1788)

Alternative names

• Trimalleolar fracture
• Pott fracture with backward dislocation of the lower fragment

References

Original articles

• Cotton FJ. Dislocations and Joint-Fractures. W.B. Saunders. 1910
• Cotton FJ. A new type of ankle fracture. JAMA. 1915;64:318–321.

Review articles

• Kleweno C, Rodriguez EK. Trimalleolar Ankle Fractures. Orthopedic Traumatology, 2018; 25: 323-334
• Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Rev. 2021 Aug 10;6(8):692-703.
• Eponymythology: Eponymous ankle and talus injuries. LITFL
• Cadogan M. Cotton fracture. Eponym A Day. Instagram

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