Updated: 12/7/2012

Approach to the Lateral Malleolus

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Introduction
  • Provides exposure to
    • lateral malleolus
    • posterolateral tibia
    • syndesmosis
  • Indications include
    • ORIF of fibula
    • ORIF of syndesmosis
    • percutaneous placement of syndesmosis screws
    • access to the posterolateral tibia 
 
Approach
  • Position
    • supine with bump under buttock
  • Incision
    • make longitudinal incision along the posterior margin of the fibula (center incision over fracture site)
    • extend 2 cm distal to the tip of the lateral malleolus (if needed)
  • Superficial dissection
    • elevate skin flaps taking care not to damage the short saphenous vein and sural nerve that runs posterior to the fibula
    • look for the superficial peroneal nerve crossing from the lateral to anterior compartments (~10 cm proximal to tip of fibula)
  • Deep dissection
    • longitudinally incise the periosteum of the subcutaneous surface of the fibula
    • strip off just enough periosteum to expose the fracture site and achieve a reduction
    • as you extend the incision proximally take care not to damage the superficial peroneal nerve
  • Extensile measure
    • proximal - may be developed proximally to become continous with the Lateral approach to the fibula
    • distal - may be extended distally to become continous with
      • Ollier's lateral approach to the tarsus
      • Kocher lateral approach to the ankle and tarsus
      • Lateral approach to the calcaneus
    • posterior
      • can access posterolateral tibia for fixation
      • interval is the peroneal muscles/tendons and flexor hallucis longus
Dangers
  • Sural nerve
    • cutting may lead to formation of a painful neuroma and numbness along the lateral skin of the foot
  • Short Saphenous vein
  • Terminal branches of peroneal artery
    • lie deep to medial surface of distal fibula
    • can be damaged if dissection does not stay subperiosteal
    • may form hematoma after removal or tourniquet
  • Superficial peroneal nerve
    • crosses from posterior to anterior over the fibular shaft at the proximal end of the incision
 

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