The anteromedial approach to the tibial shaft is through an incision placed just lateral to the anterior tibial crest.
Its most common use is for fractures of the distal third tibial shaft. However, it can be used to expose the entire anteromedial surface.
It is also useful for debridement and irrigation of open fractures when an incision on the injured subcutaneous surface is to be avoided.
The anterolateral approach, through an incision slightly lateral to the tibial crest, reflects the anterior compartment muscles from the lateral tibial surface.
This approach is used uncommonly, but may be necessary when the medial soft tissues are compromised.
Minimally invasive fixation of tibial fractures is preferably done through the medial approach, especially for distal fractures.
The lateral approach is used for minimally invasive osteosynthesis if the medial soft tissues are injured.
This approach is also used when a precontoured plate (e.g. LISS plate) is placed laterally, for fixation of proximal and mid-tibial fractures.
In the frontal plane, the entry point is located in line with the medullary canal (3 mm medial to the tibial crest). In the sagittal plane, the entry point should be located just distal to the angle between tibial plateau and anterior tibial metaphysis.
Inserting percutaneous instrumentation through safe zones reduces the risk of damage to neurovascular structures.
The posteromedial approach can be used for open plate fixation of the tibia on its posterior surface. Typically, this approach would be chosen, when direct exposure for ORIF is desired, but only the posteromedial soft tissues are safe to incise.
Note that this incision is also the one that might be used for a medial fasciotomy for compartment decompression.
The posterolateral approach can be used for open plate fixation of the tibia on its posterior surface. This may be necessary when the anterior soft tissues are compromised.
This approach is often also utilized for treatment of non-unions with posterolateral bone grafting. It allows access to both the tibia and fibula.