Case Report

Journal of Current Trends in Clinical Medicine & Laboratory Biochemistry

Posterolateral Approach To Tibial Plafond

Fractures : A Case Series
1
Raghavendra S Kembhavi*, 2
Boblee James

Abstract
Open reduction and internal fixation of tibia plafond fractures have excellent results but also associated with increased risk
of wound breakdown complications. Tibial plafond fractures have been approached through a anteromedial,anterolateral
and postreolateral approach. Posterolateral approach carries few advantages than anteromedial approach like ability to fix
both tibia and fibula through same approach, direct visualisation of posterior malleolus, lesser incidence of wound break
down complications and better soft tissue coverage over implants. However this approach is limited to specific fracture
pattern where comminution is predominantly posterior and has disadvantage of poor exposure to ankle joint compared to
anteromedial approach. In our study of six patients of tibial plafond fracture with fibular fractures and fracture subluxation
of ankle due to large posterior malleolar fragment, we used posterolateral approach we experienced stable fixation of both
tibia and fibula and no wound complications.

Key words : Posterolateral approach, Tibial plafond, Achillis tendon, Fibular plating, Antiglide mode

Introduction comminution is located predominantly in

posterior tibia along with fibular fractures and
Posterolateral approach for open reduction and
when anterior approach is not recommended
internal fixation of tibial plafond fractures has
because of condition of soft tissues. The
been better alternative to routine anteromedial
advantages of this approach are lesser incidence
approach. Which has more chnaces of wound
of soft tissue complications and hence further
break down [1]. However, this approach
infection [2-3] and ability to fix both fibula
demands specific fracture pattern in distal
and tibia through same incision and also less
tibia. This approach is recommended when
implant prominence as compared to routine
anteromedial approach due to sufficient soft
tissue coverage[4-5]. In this study of six
Assistant Professor, 2Professor,
1 patients we used posterolateral approach for
Department of Orthopaedics, Sri Lakshmi Narayana Institute of
Medical Sciences, Puducherry
open reduction and internal fixation of tibial
plafond fractures with fibula fractures and
*Corresponding Author experienced excellent results.
Dr. Raghavendra S Kembhavi
Assistant Professor of Orthopaedics,
Sri Lakshmi Narayana Institute of Medical Sciences,
Materials and Methods
Osudu,Puducherry-605502.
E-mail id: [email protected] In this study six patients who came to
Telephone Number: +919943878144 casualty of Sri Lakshmi Narayan Institute

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of Medical Sciences between May 2013 to fibula just lateral to achillis tendon[7]. The
March 2014 were admitted on emergency internervous plane being between flexor
basis. Appropriate X-Rays were taken. All hallucis longus and peroneal tendon. We used
the patients had closed fractures. Patients were prone position in all patients. Sural nerve was
admitted and worked up for surgeries with identified and isolated in all patients[8].In all
proper pre-anaesthetic investigations. Patients patients fibula was fixed first with one-third
were posted for surgeries on elective basis after tubular plate or recon plates[9].In one patient,
making sure swelling had subsided. In one due to extreme comminution in fibula,we used
patient we applied external fixator spanning tibial distractor spanning ankle. This method
ankle due to extreme swelling on emergency helped us in achieving fibular length. In one
basis. Proper consent was taken. CT scan was patient, due to low lateral malleolar fracture
taken in all patients for adequate preoperative and oblique pattern,we used one-third tubular
planning. plate in antiglide mode[10]. In one patient, we
used same approach with nail in situ which
Results was put for tibial fracture and who developed
Posterolateral approach to tibial plafond gave trimalleolar fracture afresh.
excellent reduction and stability in all six Fig.No.1: Showing trimalleolar fracture fixed
patients. One patient was applied with external cancellous screws and one third fibular plate with
external fixator spanning ankle. At six weeks external
fixator spanning ankle soon after trauma due
fixator was removed and at three months syndesmotic
to excessive swelling and internal soft tissue
screw was removed.
injury. Once swelling had subsided ,internal
fixation with cortical screws and fibular plating
was done through posterolateral approach. In
other five patients direct open reduction and
internal fixation was performed. Fixation was
stable in all patients with no intra articular
step in distal tibia and proper fibular length
was achieved. No wound complications were
seen in any of the patients and no implant Posterior malleolar component, in all patients
prominence were seen due to adequate soft were more than 25-30 % of the articular surface
tissue coverage. Clinicoradiological union was and hence decision for fixation was made[11].
seen in six months in four out of six patients. Fragment was reduced through direct
visualisation and was fixed with cannulated
Discussion screws in all patients[12]. But disadvantage
of this approach while reducing posterior
Posterolateral approach to ankle have been malleolus being poor visualisation of ankle
proved to be better approach to tibial plafond joint to know articular congruency. Hence we
fractures as compared to routine anteromedial required C-arm guidance for reducing this
approach. Benefits of posterolateral approach fragment to check articular step. Due to this
have been well documented in literature. The disadvantage of poor visualisation of ankle joint
main advantage being ,ability to approach when compared to anteromedial approach, this
both tibial and fibular fractures through same approach demands particular fracture pattern.
incision. This restricts need for two incision That is,this approach is suitable only when
,one for tibia anteromedially and one fibula comminution is predominantly posterior and
laterally[6]. In all our patients in our study, has restricted utility when comminution is
we made incision along posterior border of anterior.

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In all our patients, fracture was predominantly with external fixator, fixator was removed after
posterior malleolus. In one patient there was six weeks. All patients were started with range
associated medial malleolar fracture which of movement exercises at six weeks. However
was fixed with single K-wire by C-arm weight bearing was restricted until twelve
guidance[13]. weeks.
Fig.No. 2: Showing pre op and post operative x rays Fig.No. 4: Showing introperative pictures in a patient
of trimalleolar fracture fixed with recon plate and fixed with recon plate and cancellous screws.
cancellous screw and K wire with IM nail situ. CT
taken preoperatively also shown.

Conclusion
The other advantage of this approach being
lesser incidence of soft tissue complication The present study concludes that poster lateral
and hence wound breakdown complications. approach to tibia plafond fractures is good
The reason being sufficient muscle cover to alternative to the anteromedial apparoach
the plates by flexor hallucis longus. Due to when the fracture configuration allows to use
this wound complications and hence risk of this approach. It provides excellent exposure
infection have been reported less with this to posterior malleolus as well as fibula and
kind of approach. Hence this approach is allows to fix both through same approach
particularly useful in when skin and soft tissue under direct vision. The soft tissue coverage
condition is not favourable for anteromedial is better and hence wound complications are
approach. less. Hardware prominence is less too with
this approach. Hence we recommend this
Due to the same reason of good muscle cover approach in tibial plafond fractures involving
over plates, hardware prominence is less with posterior malleolus and lateral malleolar
this approach whereas hardware is easily felt fractures.
in anteromedial approach. We did not come
across wound complications in any of our References
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