![]() ![]() Once this provisional reduction is obtained, a buttress plate with screw placement at the apex of the fracture is applied to prevent posterosuperior migration of the fragment. A K-wire placed from posterior to anterior can aid in holding the reduction. Reduction can be achieved using a variety of techniques although our preference is for gentle pressure using a ballpoint pusher device. The fracture fragment is booked open and hematoma is irrigated from within the fracture to remove clot and any loose fragments of bone or tissue which may impede reduction. The fracture is mobilized from medial to lateral and proximal to distal to maintain the ligamentous attachment to the fragment. If medial extension is present, it can sometimes be addressed with further medial retraction of the FHL although this pattern may be better addressed using the posteromedial approach. The posterior malleolus is visualized with medial retraction of the FHL. The periosteum is then elevated off the posterior tibia. It is our preference to always address the posterior malleolus fragment first as this can aid in restoring length to the fractured fibula. It is important to identify and preserve the sural nerve located in the subdermal fat layer, as this structure enters the surgical field in approximately 80% of cases. An incision is made in the intermuscular plane between flexor hallucis longus and the peroneal tendons (Fig. ![]() The patient is positioned prone on a radiolucent table (Fig. The posterolateral approach to the ankle is the workhorse for internal fixation as this approach allows fixation of the posterior malleolus fragment as well as the fibula through a single incision. ![]()
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