- Dorsolateral to the cuboid
The dorsolateral approach is indicated for fractures of the cuboid which are displaced, and especially those fractures that have shortened. Shortening of the lateral column leads to abduction and overpronation of the forefoot. Such deformity gravely interferes normal function.
In order to localize your incision, palpate the following anatomical points.
The sinus tarsi and distal calcaneus are palpable proximally. The base of 4th and 5th metatarsal are palpable distally. The cuboid lies between those two areas.
The sural nerve which lies in the subcutaneous tissues branches in this area with dorsolateral and lateral branches. Care should be taken not to harm these.
The extensor digitorum brevis (EDB) muscle belly overlies the cuboid dorsolaterally. The peroneal tendons traverse from superior lateral to inferior lateral. The peroneus longus (PL) traverses inferiorly through the cuboid groove towards its insertion on the plantar base of the first metatarsal. The peroneus brevis tendon inserts into the base of the 5th metatarsal with the occasional peroneus tertius.
The incision begins approximately 1 cm inferior to the sinus tarsi and overlies the distal superior calcaneal prominence. It is an axial incision and proceeds along a straight line towards the lateral base of the fourth metatarsal.
It can be extended proximally to access to the sinus tarsi and the distal calcaneus, if it is fractured. Distally the incision can be extended to address cuboid and the 4th and 5th metatarsal pathology.
Protect sural nerve
The sural nerve branches in this area with dorsolateral and lateral branches. Care should be taken not to harm these.
The extensor digitorum brevis (EDB) muscle belly is then reflected dorsomedially. The peroneal longus muscle belly crosses from superior laterally and goes under the cuboid in the peroneal groove on its course to the plantar base of the first metatarsal. The peroneus brevis inserts onto the base of the fifth metatarsal. The peroneals can be retracted proximally and inferiorly. The cuboid is then exposed.
Distraction pins can be placed in the distal lateral calcaneus and proximal metaphyseal 4th and 5th metatarsals.
The calcaneal cuboid and cuboid-4,5 metatarsal joints are also exposed.