Approach to the Lateral Malleolus

  • The approach to the lateral malleolus is used primarily for open reduction and internal fixation of lateral malleolar fractures.

  • The approach to the lateral malleolus other uses include:
    1. Open reduction and internal fixation of syndesmosis ligaments.
    2. Percutaneous placement of syndesmosis screws.
    3. Access to the posterolateral tibia.

  • Supine position with bump under buttock.

  • Landmarks:
    • Lateral malleolus.
  • Incision:
    • Make longitudinal incision along the posterior margin of the fibula (center incision over fracture site)
    • Extend 2 cm distal to the tip of the lateral malleolus (if needed).

  • There is no internervous plane for the approach to the lateral malleolus.
  • The dissection is being performed down to a subcutaneous bone.

  • Elevate skin flaps taking care not to damage the short saphenous vein and sural nerve that runs posterior to the fibula.
  • Look for the superficial peroneal nerve crossing from the lateral to anterior compartments (~10 cm proximal to tip of fibula).

  • Longitudinally incise the periosteum of the subcutaneous surface of the fibula.
  • Strip off just enough periosteum to expose the fracture site and achieve a reduction.
  • As you extend the incision proximally take care not to damage the superficial peroneal nerve.

  • Proximal Extension:
  • Distal Extension: the approach to the lateral malleolus may be extended distally to become continuous with
    1. Ollier’s lateral approach to the tarsus.
    2. Kocher lateral approach to the ankle and tarsus.
    3. Lateral approach to the calcaneus.
  • Posterior Extension:
    • Can access posterolateral tibia for fixation.
    • Interval is between the peroneal muscles/tendons and flexor hallucis longus.

  • The structures at risk during the approach to the lateral malleolus include:
    1. Sural nerve:
      • cutting may lead to formation of a painful neuroma and numbness along the lateral skin of the foot.
    2. Short Saphenous vein.
    3. Terminal branches of peroneal artery:
      • lie deep to medial surface of distal fibula.
      • can be damaged if dissection does not stay subperiosteal.
      • may form hematoma after removal or tourniquet.
    4. Superficial peroneal nerve:
      • crosses from posterior to anterior over the fibular shaft at the proximal end of the incision.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Approach to the Lateral Malleolus Approach to the Lateral Malleolus Approach to the Lateral Malleolus
Images Source:
  • Surgical Exposures in Orthopaedics 4th Edition Book.

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