What is the step-by-step procedure for a fracture distal tibia treated by plating via a postero-lateral approach?

Posterolateral Approach for Distal Tibia Fracture Plating: Step-by-Step Procedure

The posterolateral approach for distal tibia fracture plating is a safe and effective technique that allows stable fixation through a thicker soft-tissue envelope while enabling simultaneous fibular fixation through the same incision when needed. 1, 2

Preoperative Planning and Patient Positioning

• Position the patient prone or lateral to optimize access to the posterolateral aspect of the distal tibia 2, 3
• For high-energy fractures with significant anteromedial soft-tissue injury, initially stabilize with a spanning external fixator and delay definitive fixation until soft tissues permit (typically staged approach) 2
• Obtain CT imaging preoperatively to fully characterize fracture pattern and plan plate positioning 4
• Administer tranexamic acid at the start of the case to reduce blood loss and transfusion requirements 4
• Consider spinal or general anesthesia based on patient factors 4

Surgical Approach and Exposure

• Make a longitudinal skin incision along the posterolateral aspect of the distal tibia, positioned between the fibula and the Achilles tendon 1, 2
• Identify and protect the sural nerve, which runs in this region and is at risk during dissection 1
• Incise the fascia between the peroneal muscle group (laterally) and the flexor hallucis longus (medially) to access the posterolateral tibia 2
• Retract the flexor hallucis longus medially to expose the posterior tibial surface 2
• If fibular fixation is required, access the fibula through the same incision by dissecting laterally—this is a key advantage of this approach 1, 5

Fracture Reduction and Fixation

• Perform thorough debridement of the fracture site, removing any interposed soft tissue or periosteum that prevents reduction 2
• Achieve anatomic reduction under direct visualization, using pointed reduction forceps or K-wires for provisional fixation 2
• For comminuted fractures, restore length and alignment first, then address articular surface if involved 2
• Apply a posterolateral locking plate (or blade plate for metaphyseal fractures) with adequate proximal and distal screw purchase 1, 2
  • Ensure at least 3-4 cortices of fixation proximally and distally when possible 1
  • Use locking screws in the distal fragment to maximize stability in osteoporotic bone 1
• Supplement with autogenous iliac crest bone graft for metaphyseal defects or comminution to promote union 2
• If medial comminution is present, consider additional medial plating through a separate incision to prevent varus collapse 1, 5

Critical Technical Points

• The posterolateral approach provides access to a thicker soft-tissue envelope compared to anteromedial approaches, reducing wound complication risk 1, 2
• Avoid this approach if significant posterior comminution exists that would prevent adequate plate purchase 5
• Do not perform fibular osteotomy—the posterolateral approach allows direct access without sacrificing the fibula 3
• Ensure the plate is positioned on the true posterior surface, not the lateral surface, to function as an effective buttress 2

Postoperative Management

• Allow protected weight-bearing initially, advancing to full weight-bearing based on fracture pattern and fixation stability 1
• Clinical union typically occurs by 14-15 weeks, with radiographic union by 20 weeks on average 1, 2
• Monitor for hardware irritation, which occurred in 16.6% of cases in one series and may require implant removal after union 1
• Obtain follow-up radiographs at 2 weeks, 6 weeks, 12 weeks, and as needed until union is confirmed 4

Expected Outcomes and Complications

• Union rates of 92-100% can be expected with this technique when properly executed 1, 2
• Deep infection rates are low (0% in reported series), though superficial wound infections occur in approximately 20% of cases and typically resolve with conservative treatment 2, 5
• Malunion risk is minimal (0-10%) when anatomic reduction is achieved and maintained 1, 5
• The approach does not compromise outcomes compared to traditional anteromedial or lateral plating methods 1

Key Advantages Over Alternative Approaches

• Single incision allows fixation of both tibia and fibula when both bones are fractured 1, 5
• Thicker soft-tissue coverage over the plate reduces wound complications compared to anteromedial approaches 1, 2
• Particularly valuable when anteromedial soft tissues are compromised by trauma or previous surgery 2
• Avoids the need for fibular osteotomy required in some traditional posterolateral approaches 3