Safe zones in the tibia for pin insertion

Inserting percutaneous instrumentation through safe zones reduces the risk of damage to neurovascular structures.

The peroneal nerve runs posteriorly at the level of the fibular head and curves anteriorly as it goes caudal.

The medial and the lateral zones at the level of and anterior to the fibular head are the only safe zones for tibial transfixation.

The anterior, medial, and lateral zones on both sides of the patellar ligament are safe for unilateral fixation.

Distal to the tibial tuberosity, fixation in the anterior and medial tibia is safe.

Fixation in the anterior and medial tibia is safe. Be careful inserting a pin from anteromedial to anterolateral, as it can damage the neurovascular bundle of the anterior tibial artery and vein and the deep peroneal nerve (as indicated by the red dotted line).

When inserting pins in the distal third of the tibia, take into account the position of the saphenous vein, anterior tibial artery, and vein. Medial to lateral pin placement is easy and safe, presuming the saphenous vein is protected. If a pin is to be inserted from anterior to posterior, a small incision will allow identification and retraction of the artery and vein, and safe hardware insertion.

The peroneal bundle is located very close to the posterolateral border of the tibia and is therefore at risk if pins are inserted in this direction.

Pins at this level can be inserted as shown in the illustration from anteromedial to posterolateral or from medial to lateral, anterior to the fibula.