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https://upload.orthobullets.com/topic/12072/images/12.jpg
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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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Questions (1)

(OBQ11.6) 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? Review Topic

QID: 3429
FIGURES:
1

Superficial peroneal nerve in the lateral compartment

34%

(374/1086)

2

Deep peroneal nerve in the anterior compartment

61%

(661/1086)

3

Sural nerve in the superficial posterior compartment

2%

(22/1086)

4

Saphenous nerve in the superficial posterior compartment

2%

(18/1086)

5

Posterior tibial nerve in the deep posterior compartment

1%

(6/1086)

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