Rockwood Adults CH64

2860

SECTION FOUR • Lower Extremity

A

B

C

D

Figure 64-24.  Percutaneous fixation of the posterior malleolus. A, B: Initial AP and lateral radiographs showing a posterior malleolar fragment involving almost 50% of the tibial plafond. C: The posterior mal- leolus is percutaneously reduced using a periosteal elevator. The scalpel shows the position of the stab incision for the anterior-to-posterior screws. D: The fracture has been stabilized with two AP screws and a fibular nail.

plate often obscures fluoroscopic assessment of the reduction of the posterior malleolus and prefer to deal with this first. The posterior malleolus can often be reduced simply by placing the heel on a radiolucent box and dorsiflexing the foot. If this fails, a small incision is made posteromedially and after careful blunt dissection, a periosteal elevator is inserted, placed on the pos- terior surface of the tibia, and used to push the fracture apex distally into a reduced position (see Fig. 64-24). The reduction is then held with the elevator or a clamp, and carefully assessed fluoroscopically in both AP and lateral planes: The lateral view may not reveal a rotational malreduction that is visible in the AP projection. Fixation is with two anterior-to-posterior, percu- taneously inserted, partially threaded 4-mm cancellous screws, placed just above the articular surface. Postoperatively, patients are usually permitted to weight-bear. In situations where an open reduction is preferred, the patient is placed prone and the posterolateral interval is used

to expose and fix the posterior malleolus with a buttress plate. The fibula is fixed through the same incision with a posterior plate.

✔ ✔ Posterior Malleolar Fixation With Posterior Plate: PREOPERATIVE PLANNING CHECKLIST

❑ R adiolucent

OR table

❑ P atient prone with appropriate bolsters under chest and abdomen

Position/ positioning aids

❑ C ontralateral side

Fluoroscopy location

❑ S mall fragment set

Equipment

❑ 250 mm Hg

Tourniquet