Lateral approach to lateral malleolus

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Introduction

  • Allows access to the posterolateral aspect of the tibia

Indications

  • ORIF of lateral malleolar fractures

Position of patient

  • Position the patient supine on the operating table, with a sandbag under the buttock of the affected limb

Landmarks and incision

Landmark
  • Identify the subcutaneous surface of the fibula and the lateral malleolus
Incision
  • 10- to 15-cm longitudinal incision along the posterior margin of the fibula to its distal end, where the center of the incision is at the level of the fracture

Internervous plane

  • No internervous plane

Superficial dissection

  • Elevate the skin flaps, taking care not to damage them
  • Be aware that the short saphenous vein and sural nerve lie posterior to the lateral malleolus

Deep dissection

  • Incise the periosteum of the subcutaneous surface of the fibula longitudinally; strip off only as much periosteum as is necessary for accurate reduction
  • All dissection should be strictly subperiosteal to avoid injuring the terminal branches of the peroneal artery

Dangers

Nerves
  • Sural nerve is vulnerable when skin flaps are mobilized
  • Cutting sural nerve may lead to formation of a painful neuroma and numbness along the lateral skin of the foot
Vessels
  • Terminal branches of the peroneal artery lie immediately deep to the medial surface of the distal fibula
  • They can be damaged if dissection does not remain subperiosteal

How to enlarge the approach

Proximal
  • Incision is extended along the posterior border of the fibula, incising the deep fascia in line with the skin incision
  • A new plane between the peroneal muscles (superficial peroneal nerve) and the flexor muscles (tibial nerve)
Distal
  • Incision is curved down the lateral side of the foot
  • Identify the peroneal tendons, the peroneal retinacula incise
  • Detach the fat pad in the sinus tarsi and the origin of the extensor digitorum brevis muscle, exposing the calcaneocuboid joint on the lateral side of the tarsus

Figures

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