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Introduction
  • Indications
    • ORIF of medial malleolus fxs
    • ORIF of pilon fxs
    • Deltoid ligament repair
Planes
  • No internervous plane
Preparation
  • Anesthesia 
    • options include
      • block vs. general
  • Preparation
    • c-arm, mini vs. full-size to confirm fracture reduction
  • Position
    • supine
    • place foot in slight external rotation to allow better visualization of medial malleolus
      • if a bump is utilized, it can be removed to allow extremity to externally rotate
  • Tourniquet
    • optional - can be used on the thigh or leg
Approach
  • Incision
    • Make 10cm longitudinal, curved incision on medial ankle
      • begin 5cm proximal to medial malleolus over subcutaneous tibia
      • continue incision across anterior third of medial mallelous
        • this can be curved apex anteriorly for improved visualization of the ankle joint
      • finish 5cm distal and 5cm anterior to tip of medial malleolus
  • Superficial dissection
    • mobilize skin flaps
    • identify and protect long saphenous vein just anterior to medial malleolus
    • identify and protect long saphenous nerve, if possible, next to vein 
    • clear remaining tissues down to periosteum
  • Deep dissection
    • expose fracture site for medial malleolus fracture
    • make small incision in anterior joint capsule to visualize joint and dome of talus
    • split fibers of deltoid ligament to allow hardware to seat directly on bone
    • posterior tibial tendon should be visualized to ensure that it remains intact
Dangers
  • Saphenous nerve
    • prevent injury by protecting and preserving the long saphenous vein
    • often too small for direct visualization
    • damage to nerve may cause
      • formation of painful neuroma
      • numbness over medial foot
  • Long Saphenous vein
    • prevent injury by mobilizing anterior skin flaps with caution
    • preservation is ideal so it can be utilized as a vein graft in future
 

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