Direct fixation of fractures of the posterior pilon via a posteromedial approach

The treatment of fractures of the posterior pilon is a timely issue. Restoration of the integrity of the incisura fibularis and subsequent anatomic reduction of the fibula are essential for reconstruction of the ankle mortise after trauma, and syndesmotic stability. Inappropriate treatment ultimately will lead to a poor functional outcome and quality of life. Open reduction and direct internal fixation through a posterolateral or posteromedial approach are increasingly preferred over indirect reduction and anteroposterior screw fixation. The posteromedial approach, although elegant, straightforward, and offering an excellent exposure of the fracture site, is used less frequently than the posterolateral approach. In this technical note we describe the posteromedial approach for the treatment of posterior pilon fractures in a step-by-step fashion. We will discuss the indications, its benefits and limitations.