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Figure 6-3. The internervous plane lies between the peroneus brevis (which is
supplied by the superficial peroneal nerve) and the flexor hallucis longus (which
is supplied by the tibial nerve).
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Figure 6-4. Mobilize the skin flaps. Incise the deep fascia of the leg in line with
the skin incision. Identify the two peroneal tendons as they pass around the
ankle.
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Figure 6-5. Incise the peroneal retinaculum to release the tendons. Retract
them laterally and anteriorly. Incise the fascia over the flexor hallucis longus to
expose its muscle fibers.
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Figure 6-6. Make a longitudinal incision through the lateral fibers of the flexor
hallucis longus as they arise from the fibula.
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Figure 6-7. Retract the flexor hallucis longus medially to reveal the periosteum
covering the posterior aspect of the tibia.
Dangers
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The short saphenous vein and the sural nerve run close together. They
should be preserved as a unit, largely to prevent the formation of a painful
neuroma (see Fig. 25-1).
The peroneal artery runs down the lower leg in a tunnel whose fibrous
roof gives attachment to muscle fibers of flexor hallucis longus. Muscular
branches wind around the fibula to supply the peroneal muscles. Branches
of the artery may be disrupted when the flexor hallucis longus is detached
from the fibula. Deflating the tourniquet before closure and ensuring
adequate hemostasis will prevent hematoma formation.
1
How to Enlarge the Approach
Extensile Measures
To enlarge the approach proximally, extend the skin incision superiorly and
identify the plane between the lateral head of the gastrocnemius muscle and
the peroneus muscle. Develop this plane down to the soleus muscle; retract
it medially with the gastrocnemius. Next, reflect the flexor hallucis longus
muscle medially, detaching it from its origin on the fibula. Continue the
dissection medially across the interosseous membrane to the posterior
aspect of the tibia.
2
REFERENCES
1. Mousa AEM, Mousa M, Singisetti K. Peroneal artery safe zone in the
posterolateral approach to the distal tibia: a CT angiogram based
anatomical study. Injury. 2022;53(3):1268–1275.
doi:https://doi.org/10.1016/j.injury.2021.09.021
2. deBoer P, Buckley R, Hoppenfeld S. The foot and ankle. In: Surgical
Exposures in Orthopaedics: The Anatomic Approach. 6th ed. Wolters
Kluwer; 2022:681–684.
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7
Lateral Approach to the Lateral
Malleolus
Position of the Patient
Landmarks and Incision
Landmarks
Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
Vessels
How to Enlarge the Approach
Extensile Measures
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Introduction
The approach to the lateral malleolus is used primarily for open
reduction and internal fixation of lateral malleolar fractures. It also
offers access to the posterolateral aspect of the tibia.
Position of the Patient
Place the patient supine on the operating table with a sandbag under the
buttock of the affected limb. The sandbag causes the limb to rotate
medially, bringing the lateral malleolus forward and making it easier to
reach (Fig. 7-1). Tilt the table away from you to further increase the internal
rotation of the limb. Operating with the patient on their side also provides
excellent access to the distal fibula, but the medial malleolus cannot be
reached unless the patient’s position is changed, something that is necessary
in the fixation of bimalleolar fractures (Fig. 7-2). Exsanguinate the limb by
elevating it for 3 to 5 minutes, then inflate a tourniquet.
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Figure 7-1. Position of the patient for exposure of the lateral malleolus.
Figure 7-2. An alternate position for exposure of the lateral malleolus. Place the
patient prone or on their side, with a sandbag under the pelvis of the affected
side.
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Landmarks and Incision
Landmarks
Palpate the subcutaneous surface of the fibula and the lateral malleolus,
which lies at its distal end.
The short saphenous vein can be seen running along the posterior border
of the lateral malleolus before the limb is exsanguinated.
Incision
The positioning and length of the skin incision depend on the pathology to
be treated and the technique to be used. If a lateral or posterior plate is to be
applied,1 make a 10- to 15-cm longitudinal incision along the posterior
margin of the fibula all the way to its distal end and continuing for a further
2 cm (Fig. 7-3A). Center the incision at the level of the fracture. If access to
the anterior syndesmosis is needed or a lag screw for a Chaput lesion is
planned, make the incision more anteriorly, along the anterior margin of the
bone.
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