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What is the internervous plane for the posterolateral approach to the tibial shaft?
sural and superficial peroneal nerves
saphenous and tibial nerves
sural and saphenous nerves
tibial and superficial peroneal nerves
superficial and deep peroneal nerves
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The posterolateral approach to the tibia is a technically demanding approach that is used when the anterior or anteromedial approaches are not possible due to skin issues. The internervous plane exists between the gastrocnemius, soleus and FHL muscles posterior (tibial nerve) and the peroneus longus and brevis anteriorly (superficial peroneal nerve). The neurovascular structures (tibial nerve, posterior tibial artery, and peroneal artery) are located between the soleus and tibialis posterior.
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What two muscles lie on the posterior aspect of the interosseous membrane and tibia in the lower leg, and must be elevated during a posterolateral approach to the tibia for treating a nonunion?
Flexor digitorum longus and tibialis posterior
Peroneus longus and peroneus brevis
Peroneus brevis and peroneus tertius
Tibialis posterior and tibialis anterior
Tibialis posterior and flexor hallucis longus
The flexor digitorum longus and tibialis posterior lie on the posterior aspect of the interosseous membrane and tibia. Flexor hallucis longus lies on the posterior border of the fibula.
The posterolateral approach to the tibia is useful to expose the middle two thirds of the tibia, and is often used when the anterior and anterior medial approaches are limited by skin issues. It is useful for plating of fractures and treatment of nonunions including bone grafting because it allows for soft tissue coverage of a bone that is otherwise subcutaneous.
The superficial internervous plane lies between the gastrocnemius/soleus (tibial nerve) and peroneal muscles (superficial peroneal nerve). The deep dissection involves detaching FHL and soleus from the posterior border of the fibula and then dissecting medially to separate the posterior tibialis off the posterior surface of the interosseous membrane and the posterior tibialis and flexor digitorum longus off the posterior surface of the tibia.
Illustration A shows a cross section of the surgical approach.
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