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A 34-year-old female sustains a pilon fracture after jumping from a ledge. An anterolateral approach is used to obtain plate fixation as shown in Figure A. Which of the following nerves is MOST at risk during an anterolateral incision and exposure of the fracture as indicated by the arrow in Figure A?
Superficial peroneal nerve in the lateral compartment
Deep peroneal nerve in the anterior compartment
Sural nerve in the superficial posterior compartment
Saphenous nerve in the superficial posterior compartment
Posterior tibial nerve in the deep posterior compartment
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The deep peroneal nerve is at risk during an anterolateral approach to the distal tibia and ankle for open reduction and internal fixation of pilon fractures.
The anterolateral approach to the distal tibia is a commonly used approach for ORIF of distal tibia and ankle fractures. This surgical dissection crosses the anterior compartment of the leg, endangering the deep peroneal nerve (DPN). The superficial peroneal nerve (SPN) is superficial to the fascia at the level of the ankle.
Herscovici et al describe the Bohler incision which is an expansile anterolateral approach to the foot and ankle. They describe its utility in exposure of the anterior surface of the distal tibia, the anterior talar dome, talar neck, talonavicular, subtalar, and calcaneocuboid joints.
Wolinsky et al performed an anatomical study on the anterolateral approach to the distal tibia. They found that the superficial peroneal nerve (SPN) is always seen in the distal incision and should be safe if adequately protected. The structures at risk with this approach are the DPN and the anterior tibial vessels as they course from a posterior position proximally to a more anterior position distally.
1- The superficial peroneal nerve is also at risk during this incision, but is on the fascia over the anterior compartment at the level of the ankle.
3- The sural nerve is not at risk.
4- The saphenous nerve is not at risk.
5- The posterior tibial nerve is not at risk.
Herscovici D Jr, Sanders RW, Infante A, DiPasquale T.
J Orthop Trauma. 2000 Aug;14(6):429-32. PMID: 11001418 (Link to Abstract)
Herscovici, JOT 2000
Wolinsky P, Lee M
J Orthop Trauma. 2008 Jul;22(6):404-7. PMID: 18594305 (Link to Abstract)
Wolinsky, JOT 2008
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