Name: Approach and Fixation Technique With the Arthrex Trauma Mini Fragment System
Uploaded: 2026-08-05T15:52:00Z
Channel: Arthrex
Description: Mitchel Obey, MD (St. Louis, MO), showcases a posterolateral approach and fixation techniques using the Arthrex Trauma Mini Fragment System for lower-extremity trauma cases.

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Mitchel Obey, MD (St. Louis, MO), showcases a posterolateral approach and fixation techniques using the Arthrex Trauma Mini Fragment System for lower-extremity trauma cases.

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VID1-008985-en-US | A | Approach and Fixation Technique With the Arthrex Trauma Mini Fragment System

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Approach and Fixation Technique With the Arthrex Trauma Mini Fragment System

Speaker  My name is Mitch Yob. I'm an orthopaedic trauma surgeon at Washington University in Saint Louis, Missouri. And today we're going to be talking about the posterior lateral approach to the ankle. This particular approach can be utilized for either ankle fractures or Pilon fracture fixation. In this particular sense we're going to be approaching the posterior malleolus, in which case the posterolateral approach is an excellent choice. When you're drawing out your incision, you're going to want to palpate out your anatomy. You're going to want to feel the Achilles tendon kind of get the lateral border of it, as well as the posterior aspect of the fibula. And then I'll tend to just make my incision essentially right down the middle of the two, usually as a straight incision. If you plan to bring it a little bit more distal. Sometimes you can also curl it off if you so desire. Oftentimes it's not as necessary, but it's another option in this particular incision. This will place you right in between the peroneals and the Achilles tendon. And also it will keep the nerve, which we will see later during this dissection, which is right underneath the skin on the lateral side of the Achilles tendon. So we will start with our approach. We will sharply incise down through the skin into the subcutaneous tissues, being careful not to go too deep and not to violate the deep fascia, as that's going to be a key structure where we identify our next plane of dissection as we get down deeper. Speaker  So once we get this dissected out, we'll get our retractors in here. So once we hit this level, we're going to proceed with our blunt dissection. As you can see, we have vascular structures on this side. And that's going to be accompanied by the Searle nerve. So with the scissors I will tease out the soft tissues along the lateral aspect of those structures so that they can then be safely retracted away throughout the rest of the case. So again, thinking about things that are of importance in the area underneath this vein is going to be your Searle nerve. So keeping your dissection all lateral to that to keep that nerve protected is critical throughout the case. So once we've hit this plane I'll take a 15 blade. Next you can see this is the fascia overlying the posterolateral structures with a 15 blade. Before you make your incision, we're going to want to identify there's a fat stripe that you can see through this fascia and you can see it's right here. It's just usually just a little bit lateral to the vein and the nerve. And so you're going to sharply incise down through that with your knife until you hit a second layer of fascia. And this is going to be the fascia that is in between the peroneals and the FHL muscle belly. And so once you identify this interval between the muscles, then you can sharply incise down through that plane with a knife. And you can find the plane that goes in between the FHL and the Peroneals. Speaker  So here we have it found on this side. You can see the FHL. And over here is going to be our Peroneals. So once we get a little bit of this fascia dissected out, then we are able to get down into that plane. You'll have a couple freer elevators ready. Oftentimes this dissection can be done with a knife. It can be done with a Metz. It can also be done with a freer elevator. Just kind of depends on your comfort and what you've been trained in. But I'll oftentimes take a couple of different freer elevators and you can kind of bluntly dissect down and that can oftentimes keep you in that plane. So that gets down through our interval between the Peroneals and the FHL, as we can see here. So important thing to take into consideration now as you reach this depth of the dissection is going to be the posterior inferior tibiofibular ligament, or one of the posterior bands of the syndesmosis that is directly attached on the posterior aspect of the fibula. So you don't want to sharply incise down through that when you're doing your dissection, because the whole purpose of repairing the posterior malleolus is to restore that stability to the syndesmosis by securing that fragment. So. So I'll oftentimes pick up on the FHL fashion. You'll be able to see a plane between that and the ligament. And you can very gently dissect it out. So you can get in between that ligament and FHL muscle belly. Speaker  You can already see these are the fibers of the posterior inferior tibiofibular ligament. They're protecting those is critical during this portion of the case. And once the FHL is elevated off, you can often bluntly dissect underneath just to ensure that you've got the right plane than we do. And there's occasionally there's some bands here distally that you need to release from the FHL and some of the adhesions it has on the back side of the posterior malleolus, and there those are released nicely. And so we'll swap out our retractors here and we'll show everything. And so that should give you a really nice look of the pitfl fibers as well. Here's the posterior malleolus fracture fragment. So here we have our dissection completely exposed. And you can see the posterior malleolus right in the middle of the screen here and the fibers of the pitfl. And so when thinking about fixing posterior malleolus fracture fragments it's I think it's very important point to talk about in terms of why we fix them, when we fix them and how we fix them. Oftentimes they're going to be a component of a trimalleolar fracture pattern. And the question comes, what size does it require it to be that you would do this approach in this dissection to fix it? And for me, most of the time, I'm going to be approaching the majority of these from the Posterolateral approach, particularly if on a lateral X-ray, you can see the fragment goes above the physeal scar on the distal tibia. Speaker  To me that makes some sense. Then that that's a large enough fragment to fix. And then the other benefit of this incision is that you can then dissect and fix the fibula fracture through this same approach. So it's two components of the fracture all done in the same surgical approach. There are occasional times when I will fix the posterior malleolus in more of a percutaneous fashion, with a wire that's placed anterior to posterior and then percutaneously through the skin out to the posterior lateral tissues, and then a cannulated screw again back through percutaneously. That tends to be a little bit more often in tibia shaft fractures with a posterior malleolus fracture component, or in a patient who otherwise soft tissues aren't amenable to this particular surgical approach. But so for the majority of these, these injuries, I'm going to be approaching the posterior malleolus from this posterior lateral approach and then fixing it directly with mini fragment fixation. And that's been supported in the literature as fixing and securing the posterior malleolus fracture fragment does increase the stability of the syndesmosis. So in my mind, there's a lot of benefits to fixing these through this approach. So in thinking about implants to secure the posterior malleolus, the go to that I've been really enjoying and having good outcomes from has been the 270 plates in the mini fragment set. There are a lot of different options that you can utilize for this. Speaker  I tend to use this two hole plate because really the goals of this particular portion of the operation are to secure this fracture and compress it down to the posterior tibia to restore that syndesmotic stability. So this particular plate has been very successful in that. And a lot of times the plates that come in the set are already a little bit too long. So you can use the cutter that's in the plate set itself to take a couple holes off. So it sits in the wound a little bit nicer. So in this particular sense we took two off and then next step is going to be contouring. And so all these plates are straight. But the posterior malleolus is a little bit more of a concave structure. So we do have to do a little bit of contouring of the plates, which again, you can utilize all of the benders that are in the plate or the implant set itself to take care of this. And so the most caudal aspect of the plate is going to be cupping around the posterior malleolus. And you can use these benders to help give it a bend that will go down around. So just a gentle bend, but you'll see how it'll be just enough that it'll cup around the posterior malleolus. And then as the plate goes proximal, you want to start a bend that goes in the other direction. So it sits fleshly on the back of the tibia. And this can be done also with these benders, just to give it a small bend towards the top. Speaker  So it lays a little bit nicer onto the top of the tibia. And again just subtle, but just enough so it'll lay appropriately on the posterior malleolus. Okay, so now we are ready to begin placement of the plate on the posterior malleolus. Now again pay attention to the anatomy of this. These are the fibers of the pitfl that's going to locate the syndesmosis for you. So the plate cannot sit on this area. Otherwise it will be traversing across syndesmosis going to be a little bit more medial to it. Provisionally placed that plate down in the wound. And then once you feel that the plate is adequately centered over your fracture fragment, then you can locate the apex of the fragment, which tends to usually be around hole three in the plate or so. But it just depends on your fracture pattern. And that tends to be the spot where you're going to place your initial Screw. That's going to act in a little bit of a buttress function to compress that apex down, as well as compressing the posterior malleolus fracture fragment reduction. So we'll then proceed with placement of the screw. And this is going to be a 2.7mm screw. We're going to be drilling with a 2.0mm drill bit. Okay. So once this plate is compressed down to bone. But before you final tighten it, I'll tend to now get an X-ray at this time to make sure that I like the plate's position on both the AP and the lateral view. Speaker  And once I've confirmed that, then I'll final tighten this plate down and proceed with placing additional screws. Once we have confirmed the appropriate plate position on both the AP and lateral views, we can then proceed with filling additional holes in the plate with cortical and or locking screws as needed, and then often a very good option for your final screw in the plate is going to be a 2.7mm KreuLock screw. That's going to work in a little bit of a hybrid fashion to not only compress intra articularly through the fracture, but it also has the locking screw head on the screw that'll lock it into the plate for more secure and rigid fixation. So this is our 2.7mm KreuLock screw going in as our final screw in the caudal aspect of the plate. And again, this provides that little extra bit of intra articular fracture reduction compression, as well as the locking screw head portion of the screw will lock into the plate securing your construct. So then at this point we have completed our fixation of the posterior malleolus fracture fragment, and then we will obtain final X-rays again to confirm appropriate plate location as well as maintenance and appropriate reduction. And then finally safety of all implants in place. In particular attention to these distal screws in the plate as those are going to be very subchondral nature and ensuring that those are all extra articular.

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Approach and Fixation Technique With the Arthrex Trauma Mini Fragment System

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