The Direct Lateral Approach to the Distal Tibia and

Fibula: A Single Incision Technique For Distal Tibial and

Pilon Fractures
1
John E. Femino, MD, 1Tanawat Vaseenon, MD

ABSTRACT significant wound healing problems with early incisions

Distal tibia fractures remain difficult injuries over the tibia whether anteromedial or anterolateral.3,4
to treat when fracture displacement precludes The anteromedial approach provides good exposure of
non-operative treatment. Dif ferent methods of the articular surface centrally and medially and allows
treatment including limited internal fixation with for placement of a medial buttress plate to support the
external fixation, as well as open reduction and comminuted metaphyseal portion of the fracture. It is
internal fixation have been recommended. Open however less advantageous for exposure of the lateral
reduction and internal fixation is often favored column of the distal tibia and the syndesmosis. This is
for the improved ability to anatomically reduce especially important in cases where the lateral tibial
displaced fractures, particularly articular fractures. plafond is dissociated from the fibula and indirect re-
However, wound complications due to the associ- duction of this lateral fragment cannot be obtained by
ated trauma to the fragile soft tissue envelope in reducing the fibula fracture. The anteromedial approach
this region continue to be a significant concern. has been associated with concerning wound complica-
The authors present a surgical approach for tions. When wound complications do occur with the
open reduction and fixation of distal tibia and anteromedial approach they can leave the distal tibia
fibula fractures through a single lateral incision, and hardware exposed. Even when healing is unevent-
which respects the angiosomes of the distal leg ful, the subcutaneous location of an anteromedial plate
and ankle. This can, in some cases, resolve the can lead to patient discomfort.3,6-8 The minimally invasive
need to delay ORIF of the tibia since the incision percutaneous plating through a medial approach has
is essentially the same as that used for the imme- been recommended by some9,10 but often the skin over
diate ORIF of fibula fractures, which is commonly the medial malleolus, which is the location of the incision
used in the staged treatment of distal tibial and for inserting the plate, is particularly thin and commonly
plafond fractures. This approach can be extended traumatized with displaced fractures. For these reasons,
proximally and distally to allow treatment of other delayed treatment has been recommended to minimize
injuries about the ankle and hindfoot. Illustrative the risk of wound complications.5
cases are provided. An anterolateral approach to distal tibial pilon frac-
tures has been described.11,12 This approach uses a
Introduction skin incision placed between the distal tibia and fibula,
Current treatment of displaced pilon fractures is fre- overlying the anterior border of the fibula. This approach
quently performed with immediate ORIF of the distal avoids the fragile medial soft tissues and allows for a
fibular fracture and delayed ORIF of the tibial plafond by single incision for plating of both the tibia and fibula
various approaches,1-4 which require temporary spanning fractures. This approach also has the advantages of uti-
external fixation of the medial side of the ankle. Delay of lizing a single incision for open reduction and internal
ORIF of the tibia is based on the concern of the risk of fixation of both the distal tibia and fibula, and provides
excellent exposure of the articular surface and lateral
plafond, and lateral column of the distal tibia.11 However,
the superficial peroneal sensory nerve is at risk as it
1
Department of Orthopaedics and Rehabilitation, University of Iowa
Hospitals and Clinics, Iowa City, IA traverses this incision and must be directly identified
Correspondence to: and retracted. Also, the anterior perforating peroneal
John E. Femino, MD artery originates from the deep posterior compartment
Assistant Professor and passes anteriorly through the hiatus that lies be-
Department of Orthopaedics and Rehabilitation
University of Iowa Hospitals and Clinics tween the proximal aspect of the syndesmosis and the
01022 JPP interosseous membrane. While this is often traumatized
Iowa City, IA 52242-1088 by the injury, and is frequently not of significant size, it
phone: 319-384-5844
fax: 319-384-8634 can be the sole dorsal artery of the foot in 3% of cases.

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J. E. Femino and T. Vaseenon

Figure 2. Exposure to the distal tibia from the single extensile lateral
approach in an extraperiosteal plane. The anterior compartment has
been mobilized with only release of the superior extensor retinaculum
and anterior compartment fascia from the intermuscular septum.

Figure 2: John Femino, Tanawat Vaseenon

Figure 1. The lateral skin incision was made between the course of
the terminal calcaneal branch and anterior perforating branch of the
peroneal artery.
Figure 1: John Reprinted
Femino, with permission
Tanawat from Attinger,C. Top
Vaseenon Vascular
anatomy of the foot and ankle.

A wound dehiscence however will occur directly over

Top
the hardware for both the tibia and fibula. Figure 3. The superficial peroneal ner ve crosses anteriorly. In this
The direct lateral approach to the distal tibia and case the ner ve was mobilized with the anterior compartment after
fibula is performed through a skin incision that is made the intermuscular septum was released. No dissection at the fascial
exit or in the subcutaneous plane was needed.
along the posterior border of the fibula, which is the
same incision used for immediate fixation of distal fibula tissue flap without the need for subcutaneous dissection
fractures. This incision is generally considered safe (Figure 3). The anterior perforating peroneal artery
for performing immediate open reduction and internal can be identified and if intact can be preserved when
fixation of the distal fibula in cases of displaced and warranted, although it rarely supplies the anterior skin
intra-articular distal tibia fractures. The deep portion of to any significant extent, since the anterior tibial artery
the dissection used to approach the tibia from the lateral usually provides most of the anterior angiosome (Figure
side does not involve any devitalization of the bone or of 4). Extension of the incision distally utilizes the standard
the soft tissue flap overlying the distal tibia. The incision lateral hindfoot approach, and the proximal extent of
preserves the angiosomes of the anterior skin over the the incision can reach the proximal third junction of the
distal tibia and ankle by keeping the anterior soft tissues tibia, and would only limited by the proximal branching
envelope completely intact and thus preserving the blood of the common peroneal nerve and anterior tibial artery
supply from the anterior tibial artery13 (Figure 1). This through the interosseous membrane.
approach provides excellent exposure of all aspects of
both the tibia and fibula fractures, and when closure is Operative Technique
performed the intact anterior compartment soft tissues A lateral skin incision is made along the posterolateral
lie over the bone and hardware, which are well away border of the fibula. At the tip of the fibula this is then
from the skin incision (Figure 2). The superficial pe- directed toward the base of the fourth metatarsal. The
roneal nerve is also maintained within the anterior soft skin incision is extended to the level of the anterior cal-

144   The Iowa Orthopaedic Journal

 Direct Lateral Approach to the Distal Tibia and Fibula
Figure 4: John Femino, Tanawat Vaseenon

Figure 4. The typical anastomosis of the anterior perforating branch of the peroneal arter y and the lateral malleolar arter y supplies the skin
over anterolateral part. Reprinted with permission from Attinger,C. Vascular anatomy of the foot and ankle. Operative Techniques in Plastic
and Reconstructive Surgery 1997;4:183 – 198.
Top

caneal process, although deep dissection distally is not

Figure 5: John Femino, Tanawat Vaseenon

necessary unless there is an associated talus, calcaneal

or cuboid fracture. The dissection is deepened to the
fibula and extraperiosteal dissection is carried anteriorly
to the anterior syndesmotic fibers and the attachment
of the superior extensor retinaculum (SER) onto the
fibula. The SER is released sharply off of the anterior
border of the fibula with care not to inadvertently cut
the underlying anterior perforating branch of the pero-
neal artery. If the vessel is intact it is usually easiest to
directly cauterize it, as it can retract posteriorly if cut at
the interosseous membrane exit (Figure 5). The only
other soft tissue attachment that must be released is the
anterior ankle joint capsule. A blunt elevator such as a
freer is passed in the extraperiosteal plane deep to the Figure 5. The anterior perforating branch of the peroneal arter y
which was sacrificed in this case does not lend any meaningful
Top

anterior compartment just above the ankle joint. This blood supply to the anterior ankle skin flap.
plane is advantageous because there are no soft tissue
attachments to the distal tibia anteriorly, as the anterior
compartment structures must glide over the bone in this
area to allow for necessary soft tissue excursion with
ankle and hindfoot motion. The anterolateral capsule

Volume 29   145

 J. E. Femino and T. Vaseenon
Figure 6: John Femino, Tanawat Vaseenon

Figure 6. Anatomic reduction and fixation of a Pilon fracture, syn-

Top

desmotic disruption and fibula fracture. A medial malleolar fracture

reduction can be visualized through the lateral incision and fixation
applied percutaneously through an incision placed distally.

of the ankle joint is thin and can be found between the

inferior aspect of the anterior syndesmotic fibers and Figure 7. (A) An anatomical reduction and internal fixation with
Figure
lateral7: John Femino,
plating of distal Tanawat
tibia and Vaseenon Top
fibula, which was not amenable to
the superior border of the anterior talofibular ligament
intramedullar y rodding due to traumatic abrasion over the knee.
(ATFL). A freer elevator is used to retract the ante- Operative treatment was performed within 24 hours of injury.(B) The
rior soft tissues, while another freer elevator is placed closed surgical skin incision of the direct lateral approach.
across the anterior ankle joint to retract the anterior
joint capsule anteriorly as well. This places the anterior
ankle joint capsule attachment onto the tibia under ten- be exposed by release of the lateral compartment from
sion. It can then be sharply elevated off of the anterior the posterolateral border of the fibula with preservation
edge of the tibial plafond. In some cases the ATFL can of the superior peroneal retinaculum (SPR). The authors
be sharply incised to allow for greater visualization of prefer to reduce and fix the tibia first to gain anatomic
the tibial articular surface. This can later be directly length and alignment and allow the fibular fracture to
repaired. Proximally the plane between the anterior and provide easier access to the tibial fracture. The syndes-
lateral compartments is followed until the superficial pe- motic incisura is reconstructed and the fibula is reduced
roneal nerve (SPN) is identified. It can run along either and fixed. Medial malleolar fractures can be visualized
side of the intermuscular septum, but most commonly and reduced from the lateral side and percutaneous
within the lateral compartment. The nerve is mobilized fixation can be placed through an incision placed distal
without the need for superficial dissection in most cases to the medial malleolus or at a later time if the medial
(Figure 3). In some cases a fibula fracture may occur at skin is too fragile even for this (Figure 6).
the fascial exit of the SPN, in which case a local release Finally, the syndesmosis can be reduced and fixed
of the nerve at the fascial exit may be prudent. At this and any remaining soft tissue reconstruction such as
point the anterior flap can be retracted medially, and the ATFL or SPR can be repaired.
broad exposure of the tibia can be appreciated (Figure
2). If the anterior perforating peroneal artery is still Proximal Extension
intact after the fracture and preserving it is preferred, The incision can be extended proximally by further-
such as in the case of a large vessel that represents the ing the mobilization of the anterior compartment off
main blood supply to the dorsal foot, then it is best to the interosseous membrane and releasing the anterior
use angled retractors rather than a straight retractor to compartment fascia from the intermuscular septum.
avoid stretching the vessel. The distal 6-7cm of the tibia There is at least one perforating vessel from the deep
can be easily approached without sacrificing the vessel, posterior compartment that will require cauterization.
but a plate can be slid beneath it and accessed above The proximal extension is limited only by the branch-
and below. Fortunately this anatomic variant is rare oc- ing of the common peroneal nerve and the tibial artery
curring only 3% of the time. Posteriorly, the fibula can exiting through the proximal interosseous membrane.

146   The Iowa Orthopaedic Journal

 Direct Lateral Approach to the Distal Tibia and Fibula

Distal Extension the extent of reduction.10,19 Articular reduction under

Distal extension of the incision can allow access to fluoroscopic imaging without direct visualization may
the lateral talus, calcaneus via the sinus tarsi and the limit full appreciation of incongruity when it exists.20
calcaneocuboid joint. The inferior extensor retinaculum
can be mobilized from the lateral talar neck for exposure Conclusion
of a talar neck fracture. The inferior extensor retinacular The direct lateral approach to the distal tibia and
attachment to the calcaneus can be released and the fibula is a useful surgical approach that utilizes a single
extensor digitorum brevis muscle reflected distally and skin incision commonly used for immediate open reduc-
dorsally to expose the calcaneocuboid joint. The sinus tion and internal fixation of distal fibula fractures. This
tarsi and posterior facet of the calcaneus are directly approach respects the angiosomes of the skin overlying
observed at this level, inferior to the Anterior talofibular the anterior ankle region, and preserves the entire soft
ligament. tissue envelope overlying the distal tibia, which allows for
complete coverage of the internal fixation upon wound
Discussion closure. The skin incision is advantageously remote
The classic principles of the treatment of pilon frac- from the hardware. The lateral column of the tibia and
tures were described by Ruedi and Allgower in 1979. syndesmosis can be directly visualized and reduced. The
They included restoration of fibular length, anatomi- superficial peroneal nerve can be minimally dissected
cal reconstruction of the articular surface of the tibia, and preserved within the subcutaneous plane. The inci-
bone-grafting to the metaphyseal defect and use of a sion can be extensile both proximally and distally, and
medial buttress plate.14 Operative treatment of distal may provide for earlier open treatment of some pilon
tibial fractures requires flexibility in choosing a treat- fractures.
ment based on the fracture pattern and soft tissue
injuries. One limitation of the classic approach of Ruedi References
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J. E. Femino and T. Vaseenon

10. Krackhardt, T., et al. Fractures of the distal tibia 17. Bhattachar yya, T., et al. Complications associated
treated with closed reduction and minimally invasive with the posterolateral approach for pilon fractures.
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tion of tibial pilon fractures using a lateral approach. p. 71-4.
J Orthop Trauma, 2007. 21(8): p. 530-7. 19. Wolinsky, P. and M. Lee. The distal approach for
12. Manninen, M.J., et al. Lateral approach for fixa- anterolateral plate fixation of the tibia: an anatomic
tion of the fractures of the distal tibia. Outcome of 20 study. J Orthop Trauma, 2008. 22(6): p. 404-7.
patients. Technical note. Arch Orthop Trauma Surg, 20. Ebraheim, N., F.F. Sabr y, and J.N. Mehalik.
2007. 127(5): p. 349-53. Intraoperative imaging of the tibial plafond fracture:
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Arteries of the skin. 1st English ed. 1988, London ; 21. Hazarika, S., J. Chakravarthy, and J. Cooper.
New York: Churchill Livingstone. xxxii, 174 p., [1] Minimally invasive locking plate osteosynthesis for
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15. Wyrsch, B., et al. Operative treatment of fractures using the Doppler to assess the arterial-arterial con-
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recommended by the AO Group. 2d ed. 1979, Berlin; son. Anatomy of the superficial peroneal nerve in
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148   The Iowa Orthopaedic Journal