Contents
- Introduction
- Indications
- Position of patient
- Landmarks and incision
- Internervous plane
- Superficial dissection
- Deep dissection
- Dangers
- How to enlarge the approach
- Figures
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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