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POSTEROMEDIAL APPROACH

USES

This approach is used for all medial and posterior malleolar fractures. Release of the posterior tibial tendon sheath is done through this approach. Long toe flexor releases can be done easily through the upper portion of this approach.

ADVANTAGES

This approach can easily be extended proximally or distally. The skin flap can be extended anteriorly far enough that the anterior medial aspect of the ankle can also be visualized, which is important when fixing malleolar fractures. In spite of creating a large flap, wound healing is generally not a problem. By extending the incision slightly posteriorly on its distal half, the approach is useful for tarsal tunnel releases.

DISADVANTAGES

This approach provides limited anterior exposure and no exposure laterally. If you need an approach to the ankle that shows the entirety of both the medial and the lateral portions of the distal tibia, an anterior approach would be more appropriate.

STRUCTURES AT RISK

The major structure at risk is the posterior tibial neurovascular bundle, which is behind the toe flexor tendon. The flexor digitorum longus and posterior tibialis tendons are in the center of this approach and can be damaged. Anteriorly, at risk is the saphenous nerve, which branches down into the medial malleolus area and, if transected, can cause neuromas trapped in the incision.

TECHNIQUE

The incision is generally 10 cm in length and centered over the posterior corner of the medial malleolus. For fracture work, the incision generally follows the course of the posterior tibialis tendon curving around to the anterior aspect of the medial malleolus. For a tarsal tunnel release, the distal half is continued in line with the flexor digitorum longus tendon and is more posterior. Once you are deep to the subcutaneous tissue, it is important to identify the toe flexor tendon. If you comedown directly over this tendon, you will not damage the neurovascular bundle. Once the superficial fascia is released, you can then carry your dissection anteriorly for fracture work or posteriorly for nerve release.

TRICKS

Related posts:

Volar Approach to the Basal Joint of the Thumb (for Bennett’s Fracture) Paronychium Approach Anterior Approach Anterolateral (Internervous) Approach Posterior Approach Anterior Approach to the Cervical Spine

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