![]() The lesser saphenous vein and sural nerve are identified and protected. We find that this gives good access to the Volkmann's fragment and optimal access to the lateral malleolus. 6 The longitudinal incision is placed just medial to the posterior border of the fibula ( Fig. If there is such a fracture, the prone approach must be used for simultaneous access to the medial side.Ī posterolateral approach is performed. Alternatively, the patient may be placed in the lateral decubitus position if there is no medial malleolus fracture. Surgery is performed in the prone position with a bump under the ipsilateral hip. 6 The rationale and nuances of the execution of this approach will be elaborated on here. The posterolateral approach has been described in the literature but has not received much attention. The purpose of this paper is to describe in detail a different method of approach and fixation that has proved very useful in the authors' experience: open reduction and internal fixation (ORIF) of trimalleolar ankle fractures using the posterolateral approach. 5 It is very difficult to get an anatomical reduction of the posterior malleolus fragment using a lateral transmalleolar approach, however, because the PITFL is attached to the unreduced fibula. Other options include arthroscopically assisted reduction 4 and the lateral transmalleolar approach. 1 This seems overly aggressive and can compromise syndesmotic integrity. An extensile posteromedial approach with dislocation of the talus laterally and complete release of soft-tissue attachments to the posterior malleolus has also been described. 3 A medial approach for a typically posterolateral fragment still would seem suboptimal. One such approach is to use the same posteromedial incision and access the posterior malleolus by incising the sheaths of the tibialis posterior and flexor digitorum longus tendons and retracting them anteriorly. The limited visualization of the posterior malleolar fragment afforded by this exposure has led other authors to describe different techniques to facilitate anatomical reduction. 2, 7 This allows fixation of the medial and posterior malleoli through the same incision. If direct exposure of the fragment is necessary, the posteromedial approach has been recommended. Further, it would seem that a supine approach to an ankle fracture with a posterior malleolus fragment fixed with screws placed anterior to posterior would be analogous to fixing a lateral tibial plateau fracture with screws from the medial side. ![]() This expected reduction is not likely if the ankle is not being fixed acutely because of the interposition of organized hematoma or callus. This fragment, also known as a Volkmann's fragment, can then be fixed with lag screws inserted from anterior to posterior. Often, the posterior fragment reduces simultaneously when the lateral malleolus is reduced because of their respective attachments to the posteroinferior tibiofibular ligament (PITFL). 1, 2 A number of different surgical approaches to this fracture have been advocated. ![]() The standard indication for fixing a posterior malleolar fracture is a displaced fragment that involves more than 25%–35% of the articular surface of the distal tibia.
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