The standard medial incision runs posterior to the medial malleolus. The saphenous vein and nerve must be protected.
Start the incision 2 cm distal to the anterior tip of the medial malleolus. Curve the incision towards the anterior edge of the medial malleolus and in the direction of the middle of the distal tibia.
Find the saphenous vein and nerve, and use a vessel loop to retract them.
The dotted line illustrates an alternative skin incision that may be used, where more anterior access is required. Take particular care not to divide the saphenous vein and nerve, which are more vulnerable with this incision.
3. Surgical dissection
Expose the anterior part of the fracture site, free the periosteum from the edges of the medial malleolus to the distal tibial joint surface and inspect the joint.
If necessary, make a vertical incision at the anteromedial edge of the joint capsule. Dissect the capsule as far as necessary to visualize the fracture and the joint surfaces.
Remove the periosteum posteriorly only sufficiently to control reduction.