Executive Editor: Peter Trafton

Authors: Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle

Distal tibia

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Glossary

Posteromedial approach

Introduction

The posteromedial exposure allows direct reduction of posterior and medial fracture fragments. A posterior plate can be placed, effectively buttressing the posterior fragments. A full thickness subcutaneous anteromedial flap can be created to allow exposure and fixation of the medial malleolus if necessary.

This approach allows for directly buttressing the posterior fracture fragments and allows a second anteromedial incision if necessary.


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Incision

The incision is centered at the ankle joint, between the Achilles tendon and the posteromedial border of the distal tibia. Proximally the incision parallels the posteromedial border of the tibia. Distally the incision parallels the path of the posterior tibial tendon.


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Superficial surgical dissection

Deepen the incision through the subcutaneous fat and fascia and reveal the deep fascia over the tendons of tibialis posterior and flexor digitorum longus, the posterior tibial neurovascular bundle and the flexor hallucis longus tendon.

For access to the posteromedial quadrant of the distal tibia, it is necessary to carefully incise the deep fascia proximally, protecting the neurovascular bundle.


Deep dissection

The interval used for deep dissection is dependent on the location of the major fracture fragments.

1) It may be between the tibia and the posterior tibial tendon. This is useful for proximal exposure only as the distal posterior tibial tendon should not be dissected from the posterior tibia.


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2) It may also be between the posterior tibial tendon and the flexor digitorum communis (see illustration).


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3) Or it may be between the flexor digitorum comminus and the flexor hallucis longus.

The latter of these three intervals requires direct exposure and protection of the neurovascular bundle along its length. The neurovascular bundle can be retracted anteromedially or posterolaterally.


Pearls

The posteromedial exposure allows direct reduction of posterior and medial fracture fragments.

A posterior plate can be placed, effectively buttressing the posterior fragments.

A full thickness subcutaneous anteromedial flap can be created to allow exposure and fixation of the medial malleolus if necessary.

Multiple deep surgical intervals can be used dependent on the fracture configuration.

v1.0 2016-11-22