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Summary: Fractures involving the posterior malleolus of the tibia Over a 6-year period, 72 patients at four Level I trauma
can be difficult to manage. Failure to address these fractures can lead centers with large displaced posterior malleolar fractures
to posterior ankle instability and altered ankle reaction forces. The were treated using a posterolateral approach to the distal
posterolateral approach to the posterior ankle provides access to both tibia. There were 26 men and 46 women, aged 18 to 91 years
the lateral and posterior malleoli. Displaced fractures of the posterior (average, 48 years). The fracture was part of a bimalleolar or
malleolus can be reduced and fixed under direct visualization through trimalleolar indirect ankle fracture in 63 cases and associated
a posterolateral incision. We have had excellent results using this with a distal spiral tibial shaft fracture in nine cases. Eight
technique for management of displaced posterior malleolar fractures patients had associated marginal impaction. Pilon fractures
with few complications. Surgeons should be aware of the effec- were excluded. The indications for fixation were displace-
tiveness of this technique for managing displaced fractures of the ment of greater than 30% of the joint surface or evidence of
posterior malleolus. posterior instability of the ankle. Fragment size and presence
Key Words: posterolateral approach, posterior malleolus, ankle of subluxation were assessed by plain films and axial
fracture, tibia fracture computed tomography scans.
(J Orthop Trauma 2011;25:123–126)
Surgical Technique
The posterolateral approach is performed in the prone
position. The leg is slightly flexed at the knee and the foot is
INTRODUCTION positioned off the end of the table or bolstered off the table to
The indications to fix posterior malleolar fractures have allow for maximal dorsiflexion during the reduction. Tourniquet
become more clear with biomechanical studies of stability and use is optional but not necessary. A longitudinal skin incision is
joint reaction force.1–7 Fractures that affect more than 30% of made in the interval between the posterior border of the fibula
the articular surface and those allowing any instability are and the lateral border of the Achilles tendon (Fig. 1). Superficial
generally reduced and fixed. These injuries may be part of an dissection involves bluntly developing the plane between the
indirect ankle fracture and have also been associated with peroneal and Achilles tendons. Care must be taken to identify
distal spiral tibial shaft fractures.8–12 The method of reduction and protect the sural nerve as it courses through the dissection.
and fixation of these injuries, however, has been given little In the deep dissection, the flexor hallucis longus muscle belly is
attention in the literature. The purpose of this study is to report elevated from the interosseous membrane and lateral tibia and is
on the use of the posterolateral approach for the reduction and retracted medially to expose the posterior distal tibia and medial
fixation of large displaced posterior malleolar fractures, edge of the fibula. Care is taken to avoid injury to the peroneal
specifically the ability to reduce and stabilize the fractures artery and its branches. The posterior syndesmotic ligaments are
and the complications associated with the technique. preserved by dissecting superficial to the ankle capsule distally.
Once the lateral tibia above the fracture is identified, the superior
extent of the fracture is visualized. Posterior malleolar fractures
Accepted for publication April 23, 2010. are typically displaced more laterally, at the level of the fibular
From the *Department of Orthopaedic Surgery, Boston University Medical
Center, Boston, MA; †Department of Orthopaedic Surgery, Washington
incisura, with a medial hinge.13 The fracture is cleaned of callus
University School of Medicine, St. Louis, MO; ‡Department of and interposed periosteum by levering the fracture distally and
Orthopaedic Surgery, University of Washington School of Medicine, working inside the fracture. In cases with impaction, the
Seattle, WA; and §Harris Methodist Fort Worth Hospital, John Peter impaction is reduced with an osteotome or bone tamp, and
Smith Orthopaedic Surgery Residency Program, Fort Worth, TX.
No funds were received in support of this work.
allograft is placed as needed.
No benefits in any form have been or will be received from Harris Methodist Once the fracture bed is clean, dorsiflexion may aid in
Fort Worth Hospital John Peter Smith Orthopaedic Surgery Residency gaining length for the reduction. However, in some cases, this
Program, a commercial party related directly or indirectly to the subject of may cause posterior translation of the talus and an anteriorly
this manuscript. directed translational force may be needed to sit the talus
Reprints: Paul Tornetta III, MD, Boston Medical Center, Department of
Orthopaedic Surgery, 850 Harrison Avenue, Dowling 2 North, Boston, anatomically under the tibia. This is evaluated on perfect
MA 02118 (e-mail: ptornetta@gmail.com). lateral fluoroscopic views. An indirect reduction of the joint is
Copyright Ó 2011 by Lippincott Williams & Wilkins performed by keying in the fracture superiorly and applying an
anteriorly directed force at the level of the joint. A ball spike or reduction should be obtained fluoroscopically. Options for
bone tamp is useful to aid in reduction. A large periarticular plate fixation include precontoured plates designed to conform
clamp can be placed around to the anterior tibial surface to to the specific anatomic region and a variety of thin plates
hold the reduction if needed. The superior, medial, and lateral appropriately contoured to the area that can be found in most
edges of the posterior fragment should be visualized to ensure fixation sets. Like with any antiglide technique, the use of a
adequate reduction. However, final confirmation of the slightly undercontoured plate acts to push the posterior