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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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3 to 5 minutes or by applying a soft rubber bandage. Then, inflate a
tourniquet (see Fig. 7-1).
Landmarks and Incisions
Landmarks
Palpate the first metatarsal cuneiform joint, by feeling along the medial
border of the foot in a distal-to-proximal direction. The first metatarsal
flares slightly at its base to meet the first cuneiform.
Continue moving proximally along the medial border of the foot to reach
the tubercle of the navicular.
The medial side of the talar head is immediately proximal to the
navicular. It can be located by inverting and everting the forepart of the
foot. The motion that occurs between the talus and the navicular is palpable
(Fig. 33-1).
Palpate the base of the fifth metatarsal by feeling along the lateral side of
its shaft in a distal-to-proximal direction until its flared base is reached; this
is the styloid process, into which the peroneus brevis muscle inserts (see
Fig. 33-3).
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Figure 33-1. Incision for exposure of the middle part of the foot. Make a
longitudinal incision directly over the area to be exposed. A dorsomedial
incision exposes the talonavicular joint, the navicular–medial cuneiform joint,
and the first metatarsocuneiform joint.
Incisions
Make a longitudinal incision directly over the area to be exposed. Use a
dorsomedial incision to expose the talonavicular joint, the navicular–medial
cuneiform joint, and the first metatarsocuneiform joint, and to reveal the
insertions of the tendons of the tibialis anterior and tibialis posterior
muscles (Fig. 34-2). Use a dorsolateral incision to expose the
calcaneocuboid joint and the base of the fifth metatarsal (Fig. 33-3; see Fig.
10-10).
If access to both the medial and lateral sides of the tarsus is required, it is
better to make two separate longitudinal incisions centered over the
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structures to be explored. Separate incisions nearly always are required for
the open reduction in fractures of Lisfranc’s joint.
Transverse incisions are used best for wedge tarsectomy.
Figure 33-2. Develop the skin flaps. Note the insertions of the tibialis anterior
and posterior muscles. Incise the joint capsules of the talonavicular joint, the
navicular–medial cuneiform joint, and the first metatarsocuneiform joint
according to the demands of the surgery.
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Figure 33-3. A dorsolateral incision exposes the calcaneocuboid joint and the
base of the fifth metatarsal.
Internervous Plane
There are no internervous planes in these approaches. Longitudinal
incisions avoid damaging cutaneous nerves. Certain major reconstructive
operations that use transverse incisions, such as wedge tarsectomy,
necessarily cut cutaneous nerves, leaving portions of the dorsum of the foot
partially anesthetic.
Surgical Dissection
Cut down directly onto the structures that are to be exposed, taking care to
avoid any cutaneous nerves that can be identified. Try to make sure that
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skin flaps are as thick as possible; minimize retraction as much as possible.
The structures of the dorsum of the foot nearly all are subcutaneous. Take
care to avoid damaging the insertions of the four powerful invertors and
evertors of the foot (Figs. 33-2 and 33-4).
Figure 33-4. Develop the skin flaps on the lateral side of the middle part of the
foot. Note the tendon of the peroneus brevis as it inserts into the base of the
fifth metatarsal. The joint capsule of the calcaneocuboid joint can be incised, if
necessary.
How to Enlarge the Approach
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These approaches can be extended proximally. On the lateral side, extend
the incision posteriorly and then up behind the posterior border of the
lateral malleolus; this exposes not only the lateral side of the ankle joint but
also the posterior part of the subtalar joint and the calcaneocuboid joint (see
Chapter 11).
On the medial side, extend the incision up behind the medial malleolus,
curving it to a point midway between the medial malleolus and the Achilles
tendon. This extension exposes those structures that pass around the back of
the medial malleolus. It is used commonly in the treatment of clubfoot,
where the neurovascular bundle must be protected (see Chapter 5).
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34
Dorsomedial Approach to the First
Metatarsal
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The dorsomedial approach to the first metatarsal provides excellent
exposure of the shaft of the first metatarsal bone. Its use is largely
confined to the open reduction and internal fixation of metatarsal shaft
fractures but can also be used for elective proximal or distal osteotomy
in posttraumatic deformity or the correction of hallux valgus. Its other
uses include the following:
Drainage of infection
Excision of bone tumors affecting the first metatarsal
Position of the Patient
Place the patient supine on the operating table (see Fig. 1-1). Partially
exsanguinate the foot either by elevating it for 3 to 5 minutes or by applying
a soft rubber bandage loosely to the foot and binding it firmly to the calf.
Then inflate a thigh tourniquet.
Landmarks and Incision
Palpate the dorsomedial surface of the first metatarsal, which is
subcutaneous and easily felt. Identify the metatarsophalangeal joint of the
hallux by moving the joint. The metatarsomedial cuneiform joint may be
difficult to palpate; if the incision is to be used for proximal osteotomy, the
position of the joint may need to be confirmed by fluoroscopy.
Make a longitudinal incision centered over the area of pathology to be
treated. In cases of trauma, make the incision over the center of the fracture
site (Fig. 34-1). The length of the incision will depend on the nature of the
pathology and the implants that are used to correct it. Take care to incise the
skin only. The terminal branches of the saphenous nerve cross the line of
the skin incision.
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Figure 34-1. Make a longitudinal incision centered over the area of pathology to
be treated. In cases of trauma, make the incision over the center of the fracture
site.
Internervous Plane
There is no true internervous plane. The bone is subcutaneous.
Superficial Surgical Dissection
Incise the deep fascia in line with the incision. Identify the terminal
branches of the saphenous nerve and ensure that they are preserved. The
nerve may need to be mobilized and retracted dorsally. Full-thickness flaps
should be created with no undermining of tissues.
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Deep Surgical Dissection
Cut down directly onto the periosteum of the first metatarsal bone. Using
blunt instruments, retract the skin fascia and cutaneous nerves to expose the
bone in the epiperiosteal plane. The extent of the deep dissection depends
on the procedure to be carried out (Fig. 34-2). In fractures, incise as small
an area of periosteum as possible to ensure maximum blood supply to the
fracture fragments.
Figure 34-2. Cut down directly onto the periosteum of the first metatarsal bone.
Using blunt instruments, retract the skin fascia and cutaneous nerves to expose
the bone in the epiperiosteal plane.
Dangers
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