All approaches to the distal tibia

This page gives guidelines to decide between an anterolateral or an anteromedial approach.

The anterolateral approach is useful for many complete articular pilon fractures, anterior and anterolateral partial articular pilon fractures, and some extraarticular distal tibia fractures stabilized with a submuscular anterior compartment plate.

The anteromedial approach is useful in many types of fractures involving the articular surface, especially if the medial malleolus is also involved.

It is a safe procedure if the correct timing is respected, usually 5-10 days after initial trauma. The skin has to wrinkle, indicating the correct time for surgery.

To prevent postoperative skin necrosis, it is important not to undermine the skin bridge between medial and any lateral approach, and to avoid violation of the anterior tibial tendon sheath.

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.

This MIO approach is used for extraarticular fractures, or for simple, minimally displaced, complete articular fractures. In the latter, the articular fracture component is not exposed, and is reduced either by indirect maneuvers using ligamentotaxis, or by the application of percutaneous reduction forceps, or directly by the percutaneously inserted lag screws.

The key concept of this approach is to preserve the soft-tissues and blood supply in the metaphyseal fracture area by not exposing them surgically.

A direct medial approach can be used for vertical medial split depression fractures with associated articular impaction. However, the risk of leaving the plate directly under the medial incision should be considered. Alternatively, the incision can be anteromedial. These fractures frequently have impaction and comminution where the fracture enters the joint. Frequently there is an independent osteochondral fragment.

This approach lends itself to fracture patterns that are primarily displaced fractures of the posterior tibia with little or no involvement of the anterior tibial surface. It has the advantage of allowing fixation of both the fibula and tibia through the same incision. It is also useful when the soft-tissue injury prevents use of the anterolateral or anteromedial exposures.

This page comprises details on safe zones for pin insertion in the lower half of the tibia shaft, the distal tibia, the calcaneus, and the metatarsals.

A detailed description of the limited open approach to the distal tibia for nailing.