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Figure 3-2. Keep the incision just anterior to the tip of the medial malleolus.
Internervous Plane
No true internervous plane exists in this approach, but the approach is safe
because the incision cuts down onto a subcutaneous bone.
Superficial Surgical Dissection
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Anterior Incision
Gently mobilize the skin flaps, taking care to identify and preserve the long
saphenous vein, which lies just anterior to the medial malleolus. Accurately
locating the skin incision will make it unnecessary to mobilize the skin
flaps extensively. The saphenous nerve runs next to the vein, and two
branches of it are bound to the vein. Take care not to damage the nerve;
damage leads to the formation of a neuroma. Because the nerve is small and
not easily identified, the best way to preserve it is to preserve the long
saphenous vein, a structure that on its own is of little functional significance
(Fig. 3-3).
Posterior Incision
Mobilize the skin flaps. The saphenous nerve is not in danger (see Fig. 3-7).
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Figure 3-3. Widen the skin flaps. Identify the long saphenous vein and the
accompanying saphenous nerve.
Deep Surgical Dissection
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In cases of fracture, the periosteum already is breached. Protect as many
soft tissue attachments to the bone fragment as possible to preserve its
blood supply.
Anterior Incision
Incise the remaining coverings of the medial malleolus longitudinally to
expose the fracture site. Make a small incision in the anterior capsule of the
ankle joint so that the joint surfaces can be seen after the fracture is reduced
(Fig. 3-4). This is especially important in vertical fractures of the medial
malleolus where impaction at the anteromedial part of the distal tibial joint
surface frequently occurs. The superficial fibers of the deltoid ligament run
anteriorly and distally downward from the medial malleolus; split them so
that wires or screws used in internal fixation can be anchored solidly on
bone, with the heads of the screws covered by soft tissue (Fig. 3-5; see Fig.
10-3).
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Figure 3-4. Make a small incision in the anterior capsule of the ankle joint to
see the articulating surface.
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Figure 3-5. Split fibers of the deltoid ligament to allow for internal fixation of the
fractured malleolus.
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Figure 3-6. The posterior incision for the approach to the medial malleolus
follows the posterior border of the medial malleolus.
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Figure 3-7. Retract the skin flaps and begin to incise the retinaculum behind the
medial malleolus.
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Figure 3-8. Anteriorly retract the tibialis posterior. Free up and retract the
remaining structures around the back of the malleolus posteriorly to expose the
posterior aspect of the medial malleolus.
Posterior Incision
Incise the retinaculum behind the medial malleolus longitudinally so that it
can be repaired (Figs. 3-6 and 3-7). Take care not to cut the tendon of the
tibialis posterior muscle, which runs immediately behind the medial
malleolus; the incision into the retinaculum permits anterior retraction of
the tibialis posterior tendon. Continue the dissection around the back of the
malleolus, retracting the other structures that pass behind the medial
malleolus posteriorly to reach the posterior margin (or posterior malleolus)
of the tibia. The exposure allows reduction in some fractures of that part of
the bone.
Note that, although this approach will allow visualization of most
fractures using appropriate reduction forceps, the angle of the approach is
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such that the displaced fragments are difficult to fix internally from this
approach. Separate anterior approaches may be required to lag any posterior
fragments back. It always is advisable to obtain an intraoperative
radiograph showing the displaced fragment fixed temporarily with a K-wire
before definitive fixation is inserted. To improve the view of the posterior
malleolus, externally rotate the leg still further (Fig. 3-8; see Figs. 10-2 and
10-3).
Dangers of the Anterior Incision
Nerves
The saphenous nerve, if cut, forms a neuroma and may cause numbness
over the medial side of the dorsum of the foot. Preserve the nerve by
preserving the long saphenous vein.
Vessels
The long saphenous vein is at risk when the anterior skin flaps are
mobilized. Preserve it, if possible, so that it can be used as a vascular graft
in the future (see Fig. 10-1).
Dangers of the Posterior Incision
All the structures that run behind the medial malleolus (the tibialis posterior
muscle, the flexor digitorum longus muscle, the posterior tibial artery and
vein, the tibial nerve, and the flexor hallucis longus tendon) are in danger if
the deep surgical dissection is not carried out close to bone (see Figs. 10-1
to 10-3).
Leave as much soft tissue attached to fractured malleolar fragments as
possible; complete stripping renders fragments avascular.
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