Lateral approach to lateral malleolus

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