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

are identified and outlined, and
the planned incision is marked in
the interval between the fibula
and the lateral border of the Achilles.
(B) Superficial dissection highlight-
ing the peroneal sheath and the
fascia of the flexor hallucis longus
(FHL). Care is taken to avoid the sural
nerve. (C) Lateral to medial dissec-
tion of the FHL off of the interosseous
membrane and distal tibia exposes
the fracture site. (D) Insertion of the
posterior plate overlying the apex of
the fracture.

anteriorly directed force at the level of the joint. A ball spike or
bone tamp is useful to aid in reduction. A large periarticular
clamp can be placed around to the anterior tibial surface to
hold the reduction if needed. The superior, medial, and lateral
edges of the posterior fragment should be visualized to ensure
adequate reduction. However, final confirmation of the
reduction should be obtained fluoroscopically. Options for
plate fixation include precontoured plates designed to conform
to the specific anatomic region and a variety of thin plates
appropriately contoured to the area that can be found in most
fixation sets. Like with any antiglide technique, the use of a
slightly undercontoured plate acts to push the posterior

FIGURE 2. Fixation of the fibula can

be addressed through the same skin
incision medial or lateral to the
peroneal tendons as dictated by
fracture orientation. (A) Superficial
dissection demonstrating location of
the fibula anterior to peroneal ten-
don sheath. (B) In this instance, the
peroneal tendons were retracted
medially to access the posterior
border of the fibula. (C) Note the
relationship of the peroneal tendons
to the posteriorly placed fibular
plate. Care is taken to avoid prom-
inent hardware distally where the
peroneal tendons glide over the
posterior lip of the lateral malleolus.
(D) The peroneal tendons are now
retracted laterally, exposing the
flexor hallucis longus (FHL) and the
fractured posterior malleolus.

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J Orthop Trauma  Volume 25, Number 2, February 2011
FIGURE 3. Radiographs show a large posterior malleolar
fracture before and after bimalleolar fixation.
malleolus anterior, ensuring maintenance of reduction and
bony contact at the fracture apex. When using an under-
contoured plate, caution must be taken to prevent over-
reduction of the fracture, resulting in distal migration of the
posterior malleolar fragment. Kirschner wires or lag screws
placed before plate fixation aid in maintaining fracture
alignment and prevent displacement from the plate. Lag
screws may be placed distal to or through the end of a plate.
The lateral malleolus may be fixed by elevating the
peroneal tendons laterally or medially through the same skin
incision. If fibular fixation lateral to the peroneal tendons is
desired, the initial skin incision should be cheated slightly
laterally or a longer incision made to avoid unnecessary
tension on the overlying skin. If the choice is made to approach
the fibula medial to the peroneal tendons, no alteration in the
initial skin incision is necessary. Fixation is performed using
a posterior or posterolateral antiglide plate (Fig. 2). Medial
malleolar fractures may be fixed in the prone position through
a separate medial incision by allowing some internal rotation
of the limb. If the tibial shaft is fractured, then the patient is
turned supine after closure and a tibial nail is placed. In this
circumstance, screws inserted to fix the posterior malleolus
should be angled to avoid the central portion of the canal to
allow for unobstructed passage of the nail. Unicortical screws
may also be used to prevent obstruction of the nail.
Closure is performed in layers with care taken to
reapproximate the flexor hallucis longus muscle belly. The
skin should be handled in a delicate manner to reduce the risk
of wound complication, similar to an Achilles tendon repair.
Patients are maintained in neutral to 5° of dorsiflexion when
not doing therapy for 4 to 6 weeks to avoid loss of dorsiflexion.
Follow-up is standard for the injury sustained.
q 2011 Lippincott Williams & Wilkins
Posterolateral Approach to the Tibia
FIGURE 4. Radiograph demonstrating distal tibia spiral fracture
with associated posterior malleolus fracture. Note the angle of
screw insertion to avoid contacting the distal nail.
RESULTS
Seventy-two patients with 72 posterior malleolar
fractures were treated using this technique. Of the 63 ankle
fractures, the lateral malleolus was fixed in 57 (90%); 16 were
fixed medial to and 41 lateral to the peroneal tendons (Fig. 3).
Tibial nails were used to stabilize the nine associated tibial
shaft fractures (Fig. 4). All patients achieved union of the
posterior malleolus with return to full weightbearing at an
average of 11 months (range, 4.5–60 months).
All patients had an accurate reduction (less than 1 mm
displaced) of the tibial joint surface based on intraoperative
fluoroscopy and initial postoperative radiographs. No losses of
reduction occurred on radiographic follow-up, and no hard-
ware irritation or loosening was seen. Dorsiflexion of the
affected ankles at final follow-up was within 5°of the opposite
side in 92% and within 10° in 8% of cases. Six patients
developed wound erythema that was treated with oral antibiotics,
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and seven patients developed some degree of skin edge necrosis.

All seven healed with local wound care. There were no deep TABLE 1. Patient Injury, Treatment, and Complications
infections. Four patients had some postoperative numbness in the Indirect Associated
Ankle Tibia
sural distribution of which three had complete resolution. One Fixation Fixation Total
patient developed a fibular nonunion (Table 1).
Number of patients 63 9 72
Fibular fixation 57 N/A 57
Lateral to peroneals 41 N/A 41
DISCUSSION AND CONCLUSION
Medial to peroneals 16 N/A 16
In complex ankle or tibial injuries associated with large
Complications Total
displaced fractures of the posterior malleolus, reduction and
All 16
fixation of the fragment is essential for the restoration of joint
Loss of reduction 0
mechanics.1,5–7 Harper, Raasch, and Hartford all demonstrated
Wound erythema 6
that injury to the posterior malleolus allows for instability if
Sural nerve injury 3
accompanied by lateral malleolar or posterior ankle ligament
Skin edge necrosis 7
injury, particularly in fragments involving 40% to 50% of the
articular surface.2,4,6 Macko also found altered joint loading N/A, not applicable.
mechanics with fragments involving greater than 30% of the
articular surface.5
Thus, the indications for fixation have evolved to include 2. Harper MC. Posterior instability of the talus: an anatomic evaluation. Foot
large (greater than 30%) fragments, those that allow for Ankle. 1989;10:36–39.
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associated with external rotation–abduction injuries. Results with and
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minimal displacement may be amenable to percutaneous Contribution of posterior malleolus and deltoid ligament. Clin Orthop
fixation techniques, typically anterior to posterior screws after Relat Res. 1995;320:182–187.
fibular fixation. However, fractures with significant displace- 5. Macko VW, Matthews LS, Zwirkoski P, et al. The joint-contact area of the
ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am.
ment are difficult to reduce closed and require open reduction 1991;73:347–351.
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