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Introduction
  • Indications:
    • ORIF of pilon fractures
    • open bone biopsy
    • access to the anterior ankle joint for debridement
 
Plane
  • Internervous plane between
    • Peroneus tertius (deep peroneal n.) 
    • peroneus brevis (superficial peroneal n.) 
 
Preparation
  • Anesthesia
    • general
    • spinal / epidural
  • Position
    • place supine on table
    • bump under ipsilateral hip
  • Tourniquet
    • exsanguinate leg (if using tourniquet) 
 
Approach
  • Incision  
    • proximally centered between tibia and fibula
    • distal extension across the ankle, centered on 4th ray
  • Superficial dissection 
    • full thickness flaps utilized
    • care must be taken to protect superficial peroneal nerve
      • located in the subcutaneous tissue, immediately under the skin
  • Deep dissection 
    • fascia incised proximally and extensor retinaculum incised over ankle
    • anterior compartment tendons elevated and retracted medially
    • minimal arthrotomy performed
      • large arthrotomies lead to devascularization of the anterior distal tibia and should be avoided
  • Proximal extension
    • indications
      • for proximal plate placement
    • dissection is limited proximally by anterior compartment muscle attachments to anterior fibula
  • Distal extension
    • indications
      • to access talar fractures or talonavicular injuries
      • to allow placement of pins for distraction
    • dissection
      • can extend incision to talonavicular joint if needed
      • extensor digitorum brevis must be elevated

Dangers
  • Superficial peroneal nerve 
  • Deep peroneal nerve 
  • Anterior tibial artery
 
   Clinical Images
     
 

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