Posteromedial Approach for Posterior Malleolus fractures

Courtesy: Anish Kadakia and Acumed LLC

Posteromedial Approach for Posterior Malleolus Fracture

(Ankle fracture fixation)

1. Plate Design Features

The Acumed Ankle Plating System 3 plates are designed to be soft-tissue friendly.

Key features:

• Distal portion: thinner profile ? reduces soft tissue irritation
  • Distal screw cluster: 2.7 mm locking screws
  • Proximal screws: 3.5 mm (locking + non-locking options)
  • Anatomical contouring for:

• Fibula
• Posterior tibia
• Medial malleolus
• Small avulsion fractures

Advantages:

• Better anatomical fit
• Less soft tissue irritation
• More stable fixation than traditional 1/3 tubular plates

Posteromedial Surgical Approach (Posterior Malleolus)

1. Goal

To expose the posteromedial tibia for fixation of posterior malleolar fractures.

2. Key Anatomical Structures

Important landmarks:

Posterior medial ankle structures:

• Posterior border of tibia
  • Posterior Tibial Tendon
  • Neurovascular bundle containing:

• Posterior Tibial Artery
• Tibial Nerve

The approach avoids the neurovascular bundle.

3. Skin Incision

Incision is made:

Between

• Posterior tibial tendon
• Posterior border of tibia

Advantages:

? Keeps surgeon away from neurovascular bundle
? Direct access to posterior tibial groove

Incision length:

• Usually short because fracture fragment is small.

4. Surgical Steps

Step 1 – Skin incision

Make incision just medial to the posterior tibial tendon along the posterior tibial border.

Step 2 – Identify tendon sheath

Expose the posterior tibial tendon sheath.

Step 3 – Open tendon sheath

Carefully incise the sheath.

Important:

? Avoid injury to the posterior tibial tendon.

Step 4 – Retract tendon

Retract the posterior tibial tendon laterally.

Now the surgeon can clearly see:

• Posteromedial tibia
  • Posterior malleolar fracture fragment

Step 5 – Periosteal incision

Incise the periosteum over the posterior tibia.

Reason:

• Posterior malleolar fractures often have thick periosteum.

Step 6 – Exposure

Use retractors (e.g., Army-Navy) to expose the entire posterior tibia surface.

Key point:

? Large exposure obtained
? Neurovascular bundle not disturbed

5. Plate Placement

The posteromedial tibial plate is placed:

• Along the posterior border of tibia
  • Inside the posterior tibial groove

Design allows:

? Anatomical fit
? Stable fixation of posterior malleolus fragment

6. Closure

Important step:

• Close the posterior tibial tendon sheath

Reason:

Prevents tendon subluxation.

However:

Risk is low due to postoperative scarring, but closure is recommended.

Key Surgical Advantages

? Safe approach
? Avoids neurovascular bundle
? Direct fracture visualization
? Good plate positioning
? Minimal soft-tissue trauma

? Clinical relevance (for anaesthesia / OT team):

During these ankle fracture surgeries:

• Patient position often prone or lateral
• Regional anaesthesia options include:
  • Sciatic Nerve block (popliteal)
  • Saphenous Nerve block

These provide excellent analgesia for posterior ankle surgery.