11 Tibia & Fibula(a)

8/4/2019 11 Tibia & Fibula(a)

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Sutgical Exposuresn Orthopaedics: The Anatomic Approach,SecondEdition by Stanley Hoppenfeld and Piet deBoer.|. B. Lippincott Company, PhiladelphiaO 1994.

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TheTibia U Fibula


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Tlr. tibia and fibul a areapproximately equal in length, but are different instructure and function. The tibia is large, transmits most of the stressofwalking, and has a broad, accessiblesubcutaneoussurface.The fibula isslender and plays an important role in ankle stability; it is surroundedbymuscles, except at its ends. Surgical approaches o the fibula are more com-plex than are those to the tibia, becauseof both the depth of the bone andthe presenceof the common peronealnerve, which winds around its upperthird.There are three main tibial approaches.The antefior approach s usedmost often because t affords easy access o the subcutaneoussurface of thebone. The anterolateral and posterclateral approachesare used rarely, butcan save he limb when skin breakdown has made anterior approaches m-possibleduring bone grafting for nonunited fractures.The approach to the fibula is classically extensile, using the interner-vous plane betweenmuscles suppliedby the superficial peronealnerve (theperonealmuscles) and those supplied by the tibial nerve (the flexor mus-cles).Although this approachcan expose he whole bone, the full approachrarely is required.

Because he surgicalanatomy of the approachesoverlap, the anatomy ofthe area s consideredas a whole.

AI{TERIOR APPROACH TO THE TIBIA

3.4.5 .6.

The anterior approachoffers safe,easyaccesso themedial (subcutaneous)and lateral (extensor)sur-facesof the tibia. It is used for the following:1. Open reduction and internal fixation of tibialfracturest2. Bone grafting for delayed union or nonunion offractures'Implantation of electrical stimulators3Excision of sequestraor saucerization in pa-tients with osteomyelitisExcision and biopsy of tumorsOsteotomy

Plates applied to the subcutaneoussurface ofthe tibia are placed correctly biomechanically onthe medial (tensile)side of the bone; they also areeasier o contour there. Somesurgeons refer o usethe lateral surface or plating, however, o avoid theproblems of subcutaneousplacement.The anterior approach s the preferredapproachto the tibia except when the skin is scarredor hasdraining sinuses n it.

POSITION OF THE PATIENTPlace he patient supineon the operating able. Ex-sanguinate the limb by elevating it for 3 to 5 min-utes, then inflate a tourniquet (Fig.11-1).484

LAI{ DMARKS AND INCI SIONLand,marksThe shaft of the tibia is roughly triangular whenviewed in cross section. It has three borders, oneanterior,one medial, and one nterosseous postero-lateral). These borders define three distinct sur-faces: {1) a medial subcutaneous surface betweenthe anterior and medial borders, l2l alateral (exten-sorl sur{acebetween the anterior and interosseousborders,and {3) a posterior (flexor)surfacebetweenthe medial and interosseous(posterolateral)bor-ders.The anterior and medial borders and the sub-cutaneoussurface are easily palpable.Incisisn,Make a longitudinal incision on the anterior surfaceof the legparallel to the anterior border of the tibiaand about I cm lateral to it. The length of the inci-sion dependson the requirements of the procedurebecause f the poorvascularity of the skin. It is saferto make a longer ncision than to retract skin edgesforcibly to obtain access.The tibia can be exposedalong ts entire length (Fig. 11-2).INTERNERVOUSPLANEThere is no internervous plane in this approach.The dissection essentially is subperiosteal anddoesnot disturb the nerve supply to the extensorcompartment.


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Figure 11-1. Position or theanteriorapproacho the tibia.

SUPERFICIII SURGICAL DIS SECTIONElevate he skin flaps to expose he subcutaneoussurface of the tibia. The long saphenous ein is onthe medial side of the calf and must be protectedwhen the medial skin flap is reflected(Fig. 1-3).DEEP SURGICAL DISSECTIONTWosurfacesof the tibia can beapproached hroughthis incision.Subcutane us (Medial) SurfaceThe periosteum of the tibia provides a small butvital blood supply to the bone n fractures that inter-fere with its main blood supply. For this reason,periosteal stripping must be kept to an absoluteminimum. In particular, never strip the periosteumoff an isolated fragment of bone, or the bone willbecome totally avascular.To expose he bone, ncise the periosteum longi-tudinally in the middle of the subcutaneoussurfaceof the tibia. Reflect it anteriorly and posreriorly touncover only as much bone as s absolutelyneces-sary {Fig. 1l-4). Note the superior insertion of thepes anserinus into the subcutaneous surfaceof thetibia. Detach it if that portion of the bone needs o beexposed,but this rarely is necessary.Lateral (Extensor)SurfaceIncise the periosteum longitudinally over the ante-rior border of the tibia. Reflect the tibialis anteriormuscle subperiosteally and retract it laterally toexpose he lateral surface of the bone. The tibialisanterior is the only muscle to take origin from thelateral surface of the tibia; detaching the muscle

Chapter 11 The Tibia l Fibuta 485

completelyexposeshat surface seeFigs. l-4 andl 1 - 2 1 ) .DAI{GERSVesselsThe long saphenousvein, which runs up the medialside of the calf, is vulnerable during superficial sur-gical dissectionand should be preserved or futurevascularprocedures,f at all posiible (seeFig. I I -2 )SPECIAL SURGICAL POINTSSkin flaps must be closedmeticulously aftersurgeryto avoid infection of the tibia. Although longitudi-nal incisions over the tibia heal well, transverseincisions and irregular wounds may heal poorly, es-pecially in elderly individuals. The skin over thelower third of the tibia is very thin; wounds in thatarea heal badly, especially in patients with chronicvenous insufficiency.It is important to minimize the amount of softtissue that is stripped from bone in this approachwhen it is used for fracture work. Devascularizedbone, no matter how well it is reduced and fixed,will not unite. Using care andappropriate reductionforceps, t usually is possible o preservesoft-tissueattachments of all but the smallest fragments ofbone.HOW TO ENLARGE THE APPROACHLocal MeasuresThe extent of the exposure s determined by the sizeof the skin incision; the whole subcutaneous sur-face of the tibia may be exposed, f necessary.


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486 Surgbal Exposuresn Orthopaedics: he AnatomirApproa.ch

Figure I 1-2. Make a longitudinal incision on the ante-rior surface of the leg.


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Clnpter 11 TheTibin CtFibula

Fasciaovert ib ia l is nter ior

Figure 11-i . Elevate he skin flaps over the medial portion of the tibialis anterior andthe subcutaneousmedial surfaceof the tibia. To expose he lateral surfaceof the tibia,incise the deep ascia over the medial border of the tibialis anterior.

487

I

f?-Tt

\l /

To reach the posterior surfaceof the tibia froman anterior approach, continue the subperiostealdissection posteriorly around the medial border.Proximally lift the flexor digitorum longus muscleoff the posteriorsurfaceof the tibia subperiosteally.Distally, lift off the tibialis posterior muscle. Thisprocedureexposes he posteriorsurfaceof the bone,but does not offer as full an exposureas does theposterolateralapproach. t probably is useful onlyfor the insertion of bone graft aspart of an internalfixation carried out through this anterior route.ExtensilcMeasures

PROXIMALEXTENSION. o extend the approachproximally, continue the skin incision along themedial side of the patella. Deepen the incision

through the lateral patellar retinaculum to gain ac-cess o the lateral compartment of the knee.DISTALEXTENSION.o extend the approachdis-talIy, curve the incision over the medialiide of thehind part of the foot. Deepening he wound providesaccess o all the structures that pass behind themedial malleolus. Continue the incision onto themiddle and front parts of the foot. (Fordetails, seeAnterior and Posterior Approaches to the MedialMalleolus in Chapter 12.)


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488 Surgiral Exposures n Orthopaedics:The Anatomic Approarh

t -_I

\ l| - - - i l

Periosteum

Tibia (fracture)

T ib ia l isanter ior

Figure 11-4. F,levatehe tibialis anterior from the lateral surfaceof the tibia. Incise theperiosteum; elevate t only as necessary.

AI{TEROLATERAL APPROACH TO THE TIBIA

- r t r \It

Tha anterolateral'approach is used to expose hemiddle two thirds of the tibia when the skin overthe subcutaneous surfaceof the bone is unsuitablefor adirect anterior approach.t is used or (1)antero-lateral bone grafting of the tibia and (2) tibia pr-ofibula grafting (REF)(cross-tibiofibular grafting)."This approach s technically simple. Becausetonly provides limited exposure of the tibia, itusually is inadequate for the internal fixation offractures.POSITION OF THE PATIENTPlace he patient on his or her side with the affectedlimb on top. Protect the bony prominences of thebottom leg to avoid the development of presswe

sores.Exsanguinate the limb either by elevating itfor 5 minutes or by applying a compressionbandageand then inflating a tourniquet.

LAI,IDMARKS AN D INCI SIONLand,marksPalpate he subcutaneoussurfaceof the fibula in thedistal third of the limb. AIso palpate he fibula headproximally.IncisionMake a longitudinal incision that overlies the shaftof the fibula, centering it at the level of the tibialpathology. The length of the incision dependson the


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Chapter 11 The Tibia t Fibula 489length of the tibia that must be exposed.Note thatthe length of tibia exposedwill be considerablyshorter than the length of the fibula incision(Fig.11-s) .INTERNERVOUSPLANESuperficially, the internervous plane lies betweenthe peroneusbrevis muscle (which is supplied bythe superficialperonealnerve)and the extensordig-itorum longusmuscle (which is suppliedby the deepperonealnerve).Deeply, he internervous plane ies between hetibialis posterior muscle (which is suppliedby thetibial nerve) and the extensormusclesof the ankleand foot (which are supplied by the deepperonealnerve).Thesemusclesare separated y the interos-seousmembrane.SUPERFICIAL SURGICAL DISSECTIONDeepen he incision, taking care not to damage heshort saphenous ein that may appear n the poste-rior aspectof the wound. Incise the fascia n the lineof the skin incision and dentify the underlying per-o_neal uscles Fig.11-5).Developa planebet#eenthe anterior aspectof the peroneusbrevis muscleand the extensordigitorum longusmuscle to comedown onto the anterolateralaspectof the fibula (Fig.1l-7). Protect the superficial peronealnerve,whic-hcan be seen ying on the peroneusbrevis muscle.DEEP SURGICAL DISSECTIONGently detach the extensor musculature from theanterioraspectof the interosseousmembraneusingblunt instruments. Follow he anterioraspectof thismembraneonto the lateral borderof the tibia (Fig.11-8).Becausehis approachalmost always s usedin casesof trauma, the plane often is difficult to

develop.Make sure to stay firmly on the intero-sseousmembrane; straying anteriorly may causedamage o the anterior neurovascularbundle. Ex-pose th-eposterolateral corner of the tibia. Gentlystrip off asmuch tissueasnecessaryrom the lateralaspectof the tibia, elevatingsomeof the origin of thetibialis anterior muscle in the process.As in allapproacheso the tibia, only the minimum amountof soft tissuethat is required o gainadequate ccessshould be dissected to avoid devasculirizatron oIbone.DANGERSVessels nd.NeruesThe small saphenousvein may be damaged n theposteriorskin flap (seeFig. 1L-6A1.The superficial peronealnerve runs down theleg g the peronealor lateral compartment. It givesoff all its motor branches n the upper third o-f heleg. Hence, it is sensoryonly at the level of thisapproach. dentify and preserve he nerve to avoidnumbnesson the dorsumof thefoot (see ig. l-78lt.The anterior tibial arteryand the deepperonealnerve run down the leg in the anterior compart-ment, which is anterior to the interosseousmem-brane. Therefore, as long as the plane of operationremains on the interosseousmembrane and doesnot wander off anteriorly, no damage will resultuntil the periosteum of the tibia is reached.HOW TO ENLARGE THE APPROACHLocal MeasuresThe longer the incision, the less retraction that isrequired for adequatevisualization.ExtensilcMeasuresThis app_-roachannotbe extendedeasilyproximallyor distally.

Figure 11-5. Make a longitudinal incision centered over the site of the fracture.


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Extensor igitorum Peroneus revisrongusSuperficialperonear .

Anterioribialn. anddeepperoneal .Superficialeroneal . i b i aPeroneusongus nd Interosseousembrane

Flexor igitorumongusTibialis osteriorteriorib ia l . ,v. ; peroneal

Soleus v.;and ibial .rocnemrusFi.gure11-6. (A! Identify the peronealmuscles and the short saphenousvein.Inl tdentify the plane between the peroneusbrevis and the extensor digitorum longus.

Extensor igitorumcommunls

Peroneuslongus Extensordigitorumrongus

Extensorhal lucislongus

Fibula

Extensordigi torumongusPeroneus revis Fibula

Superficialperonealn .Peroneuslongus ndbrevis

--.- lnterosseousmembrane

* @ , @ , . - L Zrota%*Superficial

Anter iorib ia l . ,deepperoneal .Tib ia

Figure 1I -7 (A) Developaplane n a distal to proximal directionbetween he peroneusbr&is and the extensordigitorum longus.(B) Note the superficial peronealnerve lying on the peroneusbrevis muscle.490


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Chapter 1I The Tibia l Fibuta 491Extensordigitorumrongus, Interosseousmembrane Superficialperoneat .

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Peroneus revisAnterioribial4. ,v. ;oeepperoneal.

Interosseousmembrane

Superficialperoneal .Fibula

Peroneuslongus ndbrevis

Figure I !'q. Developaplaneby detaching he extensormusculaturefrom the anterioraspectof the interosseousmembrane to .ipor" the posterot"i.i"f .t*er of the tibia.

POSTEROLATERALAPPROACH TO THE TIBIA

1 .2.

The -posterolateral pproachas used to expose hemiddle two thirds of the tibia when the skin overthesubcutaneoussurface s badly scarredor infected. tis a technically dema_ndingperation.The approachis suitable for the following-uses:

Incision,n_r".k. longitudinal incision overthe lateral borderot the gastrocnemiusmuscle.The length of the inci-sion dep-eldson the length of bone"th"lm"st beexposedFig. l-10).INTERNERVOUSPLANE

SUPERFICIAL SURGICAL DISSECTION

Internal fixation of fracturesTreatment of delayed union or nonunions offractures, ncluding bone grafting!h9 approachalsopermits exposureof the mid-dle of the posterior aspectof the fibula.

POSITION OF THE PATIENTPlace he patient on his or her side,with the affectedfeguppelmost. Protect he bonyprominencesof thebottom leg to avoid the deveiopm.trt of pressuresores.Exsanguinate he limb by elevating it for 5minutes, then apply a tourniquet (Fig. l l:91.LANDMARK AND INCISIONLandrnarkThe lateral border of the gastrocnemiusmuscle iseasyto palpate n the calf.


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492 Surgiral Exposures n Orthopaedics: The Anatomir Approach

Find the lateral borderof the soleusand etract twith the gastrocnemiusmedially and posteriorly;underneath,arising rom the posteriorsurfaceof thefibula, is the flexor hallucis longus (Fig.11-13).DEEP SURGICAL DISSECTIONDetach the lower part of the origin of the soleusmuscle from the fibula and retractit posteriorlyandmedially. Detach the flexor hallucis longus muscle

from its origin on the fibula and retract t posteriorlyand medially (Fig.1I-14, seeFig. 11-13).Continuedissectingmedially across he interosseousmem-brane,detaching hose ibers of the tibialis posteriormuscle that arise rom it. The posterior ibial arteryand ibial nerve areposterior o the dissection,sepa-rated rom it by the bulk of the tibialis posteriorandflexor hallucis longus muscles (Fig. 1l-15). Followthe interosseousmembrane to the lateral border ofthe tibia, detaching he muscles that arise rom its

ei

Gastroc-soleus as s

Figure 1I-9. Position for the posterolateralapproach o the tibia.

Figure 11-10. Incision of the lateral border of the gastrocnemius.

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posteriorsurfacesubperiosteally, nd exposets pos-terior surface Fig.11-15).DAI,IGERSVesselsThe small (short)saphenous ein may be damagedwhen the skin flaps are mobihzed. Although thevein should be preserved f possible, t may be lig-ated, f necessary,without impairing venousreturnfrom the leg.Branchesof the peronealartery cross he inter-muscular plane between the gastrocnemius andperoneus brevis muscles. They should be ligated

493

or coagulated o reducepostoperativebleeding(seeFig. 1L-271.The posterior tibial artery and tibial nervearesafe as long as the surgical plane of operationremains on the interosseousmembrane and doesnot wander into a plane posterior to the flexorhallucis longusand tibialis posteriormuscles (seeFig. I -271.HOW TO ENLARGE THE APPROACHExtensileMeasures

PROXIMALEXTENSION. he approach cannotbe extended nto the proximal fourth of the tibia.

Chapter I1 The Tibia U FibulaPeroneusongus(superf ic ia l eroneal . )

Lateral ol e astrocnemius(t ibialnerve)[[fi'Ji' ucisonsus

Figure 11-11. The internervous plane lies between the gastrocnemius, soleus,andflexor hallucis longusmuscles(which are suppliedby the tibial nerve) and the percnealmuscles (which are supplied by the superficialperonealnervel.

Fasciaoverperoneus ongus

,-.=./E{'

,_ . r_ ; /L-*--=:ll

Fasciaover ateraheadof gastrocnemiusFigure 11-12. Reflect he skin flaps. ncise he fascia n line with the incision. Find theplane between the lateral head of the gastrocnemius and soleus posteriorly, and theperoneus brevis and longus anteriorly.

Fasciaoversoleus


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494 SurgiralExposuresn Orthopaedics:heAnatornbApproafiSoleus or ig in) Lateral dgeof f ibula

F lexo r a l l uc i songuseroneus rev is

tt \ ."\f l l J 1-r !r l . '

f t l

L*",-,t

I \1. ,'' \ i ?-I t, . _ " t ) Ii ( t\ t l\ - - * -

, - - - ; P - ' *n ? t A

Fasciaover ateralheadof gastrocnemius

_ - * s i f l : : :

Soleus(detached)

F ibu laPeronei

There, the back of the tibia is coveredby the pop-liteus muscleand he more superficialposterior ib-ial artery and tibial nerve, making safedissectionimpossible.

nterosseousmembranextensord ig i t o rum

ter iort ib iala .T ib ia l i santer ior

Deepperonealnerve

DISTALEXTENSION. he approachcan be madecontinuous with the posteriorapproach o the ankleif the skin incision is extendeddistally between heposterior aspect of the lateral malleolus and theAchilles tendon.

GastrocnemiusFlexorha l luc il ongus

Peroneal .Posteriort ib iala .

t iO ia t i s T ib iaposteriorFigure 11-13. Detach the origin of the soleus rom the fibula and retract it posteriorlyan? medially along with the gastrocnemius.Retract the peronealmuscles anteriorly.Detachthe flexorhallucis longus rom its origin onthe fibula. Develop he planebetweenthe gastrocnemius-soleus oup posteriorly and the peronealmuscles anteriorly (crosssectionl.Note the flexor hallucis longus on the posteriorsurfaceof the fibula.

APPROACH TO THE FIBULAThe approach o the fibula employs a classicexten-sile exposure6 nd offers access o all parts of thefibula. Its uses nclude the following:

teotomyT or as part of the treatment of tibialR Ononunlon-'-Resectionof the fibula for decompressionof allfour compartments of the legloResectionof tumors2.

l. Partial resection of the fibula during tibial os- 3.


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Chapter 1I The Tibia U Fibula 495

Peroneusongus

Fasciaover ateralhead of gastrocnemius

4. Resection or osteomyelitis5. Open reduction and internal fixation of frac-tures of the fibula6. Removalof bone graftsAlthough the bone can be exposedcompletely,only ^ paft of the approachusually is required for

any one procedure.POSITION OF THE PATIENTPlace he patient on his or her side on the operatingtablewith the affectedsideuppermost.Pad he bonyprominencesof the other leg o prevent he develop-ment of pressuresores.Exsanguinate he limb byelevating t for 3 to 5 minutes, then apply a tourni-quet (seeFig. 11-9).Alternatively, f this approachsused n conjunction with a surgicalapproach o the

Soleub(detached)Figure 11-14. Detach the flexor hallucis longus rom its origin on the fibula and retractit posteriorly and medially. Continue dissectingposteriorly, staying on the posteriorsurface of the fibula. Detach the flexor hallucis longus from its origin on the fibula,staying close to the bone (crosssectionl.Retract the muscle medially.

----*-


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496 SurgicalExposuresn Orthopaedics:heAnatomirApproail

Peroneusonglnterosseousmembrane

Lateraledge of t ibia

Flexorhal luc is ongus

T ib ia l i sposter ior

Interosseousmembraned ig i t o rumlongus

Anter iort ib iala .Flexorhal luc islongus T ib ia l i santer iorSoGastrocnemius Deepperonealn.

Peroneal .

Incision,Make a linear incision just posterior to the fibulabeginning behind the lateral malleolus and exrend-ing to the level of the fibular head. Continue theincision up and back, a handbreadthabove he headof the fibula and in line with the biceps femoristendon. Watch out for the common peroneal nerve,which runs subcutaneously over the neck of thefibula and can be cut if the skin incision is too bold.The length of the incision dependson the amount ofexposureneeded Fig.1L-I7ll.INTERNERVOUSPLAT{EThe internervous plane lies between the percnealmuscles, supplied by the superficial peronealnerve,

Tib ia l i . T ib iaFlexord ig i t o rumlongusib ia la .

and the flexor muscles, supplied by the tibial nerve(see ig.11-11) .SUPEEFICIAL SUNGICAL DISSECTIONTo expose he fibular head and neck, begin prox-imally by incising the deep ascia n line with theincision, taking great care not to cut the underlyingcommon peronealnerve. Find the posterior borderoJ le bic,epqemoris tendon as t sweepsdown pastthe kneebefore nserting into the headbf the fibula.

Peronei


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Chapter II The Tibia U Fibula

T ib ia l i s

Peroneuslongus ,Tibia

PeriosteumFlexorhal luc islongus53i""J3""'

Figure 11-16. Detach the muscles that arise from the posterior surfaceof the tibiasubperiosteally. ,xpose he posteriorborderof the tibia subperiosteally cross sectionl.The detached ibialis posteriormuscle protects the neurovascularstructures.

CommonperonealHeadof f ib

i 4 w t ;

Fibu

,* i i l l ;b.rrl16lejhr @iS d @) ii-s2Lildil(+) .,*,@riliiid.)ratlL i!:]S.roti,F)@ild r 1 " "" ; ; 1

i i(dLi$ri ii+:l.1ire:,; tli:rtdlr :,, :ia:l

Figure 11-17. Make a long linear incision just posterior to the fibula.

; ; ; I


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Commoh

Fasciaoverperoneus


498 SurgfualExposuresn Orthopaedics:heAnatomitApproail

the nerve and gently pulling the nerve forward overthe fibular head with a strip of corrugatedrubberdrain. Identify andpreserveall branchesof the nerve(Fig.11-1e) .Develop a plane between the peronealand thesoleus;with the common peronealnerve retractedanteriorly, incise the periosteumof the fibula longi-tudinally in the line with this plane of cleavage.Continue the incision down to bone (Fig.11-20).DEEP SURGICAL DISSECTIONStrip the muscle off the fibula by dissection. Allmuscles that originate from the fibula have fibersthat run distally toward the foot and ankle. There-fore, to strip them off cleanly, you must elevatethem from distal to proximal. Most muscles origi-

Figure 11-18. (A) Expose he commonperonealnerve in the proximal end of theincision along the posterior border of thebiceps.(B)Continue exposing he common per-onealnervedistally as t winds aroundtheneck of the fibula in the substanceof theperoneus ongus.

nate rom periosteumor fascia; hey can bestripped.Muscles attached directly to bone are difficult tostrip; theyusually must be cut (Fig. 1-21 and c.ross-section).The other structure attached to the fibula, theinterosseousmembrane,has ibers that run obliquelyupward. To complete the dissection,strip the in-terosseousmembrane subperiosteally from proxi-mal to distal (Fig.1l-22 and uoss-sectionl.

DANGERSNeraesThe common peroneal nerve is vulnerable as itwinds around the neck of the fibula. The kev to

Fasciaoverbiceps emori

Common Fasciaover ateralheadof gastrocnemius


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Chapter 11 The Tibia U Fibula

Fasciaover

499Commonperoneal .

Fasciaoverbiceps emo neusbrevis

Fasciaover soleusFascia ver ateral eadof gastrocnemius

Figure 11-19. Retract the peronealnerve anteriorly and ncise the fasciabetween heperonealmuscles and the soleusmuscle.

preserving he nerve s to identify it proximally as tlies on the posteriorborder of the biceps emoris. Itthen can be safely raced hrough the peronealmus-cle massand retracted.The dorsalcutaneousbranchof the superficial peronealnerve is susceptible oiniury at the iunction of the distal and middle thirdsof the fibula; if it is damaged,t causes umbnessonthe dorsum of the foot (seeFig. 1l-30).VesselsTerminal branchesof the peronealartery lie close othe deep surfaceof the lateral malleolus. To avoiddamaging hem, you must keepthe dissectionsub-periosteal seeFig. 1l-27lr.The small (short) saphenous ein rrraybe dam-aged;you may ligate it if necessary.

HOW TO ENLARGE THE APPROACHLocal MeasuresThe exposuredescribedallows exposureof the en-tire bone.ExtensileMeasures

DISTALEXTENSION.xtend the skin incisiondistally by curving it over the lateral side of thetarsus. To gain access o the sinus tarsi and thetalocalcaneal, talonavicular, and calcaneocuboidjoints, reflect the underlying extensor digitorumbrevis muscle. This extension is used frequentlyfor lateral operations on the leg and foot (seeLateral Approach to the Hindpart of the Foor inChapter 2).

APPLIED SURGICAL AI{ATOMY OF THE LEGOVERVIEWThe tibia and fibula are very different bones. Thetibia has a large subcutaneoussurface hat allowsaccesso the bone along ts entire length; the fibulais enclosedalmost completely n muscle.Only at itsproximal end and n the lower third of the bone doesthe fibula develop a subcutaneous surface, whichterminates in the lateral malleolus. For his reason,operationson most of the fibula almost always n-volve extensive stripping of muscle off bone. n addi-tion, the tibiahas no majorneurovascularstructuresrunning directly on it other than its nutrient afteryithe fibula has close ties to the common peronealnerve and its branches.

The deep fascia of the leg is a tough, fibrous,unyielding structure that encloses he calf muscles.Where the bones become subcutaneous/ he fasciausually is attached to the border of the bone.TWo ntermuscular septa,one anterior and oneposterior, pass rom the deepsurfaceof the encir-cling fascia o the fibula and enclose he peronealorlateral compartment of the leg.Threeseparatemuscular compartments exist nthe lower leg (Fig.1I-231.Anterior (Extens r) CompartrnentThe anterior compartment contains the extensormusclesof the foot and ankle. ts medial boundary s


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Commonperoneal .

Fasciaoverbiceps emoris

Commonperoneal. ..


longus

Gastrocnemtus

Neckoff b u l a


Neckoff b u l a


Soleus

Peroneuslonguq

Soleus detached)

F ibu la

Tib iaFlexord ig i t o rumlongus

Peroneuslongus Lateraledgeo f f i bu la

Perforat ingarteriesFlexorlongus

Figure 11-20. Developthe intermuscular planebetween he peronealmusclesand thesoleus muscle down the lateral edgeof the fibula. Strip thellexor muscles from theposterior aspectof the fibula in a distal to proximal direction.

emori

Extensord ig i t o rumlongusPeroneal .

pperoneal .i b ia l i s

F ibu la Peroneus revis

FlexorlongusSoleus

Figure 11-21 Strip the flexor hallucis longus and thesoleus rom the posterioraspectof the fibula, and stripthe peroneal muscles from the anterior surface of thefibula in a distal to proximal direction. Strip the flexormuscles from the posterior aspectof the fibula (crosssectionl. Avoid neurovascular structures by stayingclose to the bone.Posteriort ib iala .

Flexorhal luc is

500

T ib ia ln ; anter ior


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Chapter II TheTibia U Fibula

Peroneusongus

Fasciaover ateheadof gastrocnemius F lexo r a l l uc i slongusFigure 11-22. Retract the peronealmuscles anteriorly. Strip the interosseousmem-brane from the anterior border of the fibula in a proximal to distal direction. Strip themuscles rom the anterior surfaceof the fibula and strip the interosseousmembrane fromits fibular attachment in a proximal to distal direction (crosssectionl.

50 1

Com m onperoneal .

Fasciaoverbicepsfemor is

the lateral (extensor) surface of the tibia, and itslateral boundary is the extensorsurface of the fibulaand anterior intermuscular septum. The anteriorcompartment is enclosedby the deep asciaof theleg and all its muscles are supplied by the deepperoneal nerve. The compartment's artery is theanterior tibial artery.Lateral (Peroneal)CompartmentThe peronealcompartment is boundedby the ante-rior intermuscular septum in front, by the posteriorintermuscular septum behind, and by the fibula me-dially. It contains the peronealmuscles/ which evertthe foot. The superficial peroneal nerve supplies all

Achi l les endon

the muscles n the compartment.No artery runs init; its muscles receive their supply from severalbranches of the peroneal aftery.Posteriar (Flaor) CompartmentThe flexor compartment contains the flexors of thefoot andankle. This compartment is separatedromthe other compartments by ^ fibro-osseouscom-p,lex: aterally, from the peroneal compartment, bythe posterior intermuscular septum and the poste-rior medial surfaceof the fibula; and anteriorly, fromthe extensor compartment, by the interosseousmembrane and the posterior (flexor) surface of the


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502 Surgiral Exposures n Orthopaedi.cs:The Anatomit ApproarhANTERIOR

Tibial is nter ior Interosseous embraneFasciaoveranter ior ompart -ment Peronealarteryan d veins

Anter ior ib ia larteryand veinsDeepperonealn. F lexo r i g i t o rum ongus

Extensor a l luc is ong Tib ia l is oster iorExtensor igi torum onguoster ior ib ialIntermusculareptum arteryand vein

Tib ia lnerveuperf ic ia l eroneal :Peronei Septumof deepf lexorcompartmentFasciaoverperoneal ompartment F lexo r a l l uc i songus

ascraoverntermusculareptumGastrocnemius

POSTERIOR

tibia. The tibial nerve nnervatesall the muscles nthe compartment, and the posterior tibial arterysupplies hem with blood. The peronealartery alsoruns in this compartment and forms part of theblood supply of the muscles.

f lexorcompartmentFigure 11-23. The fibro-osseouscompartmentsf the leg.

The flexor compartment consists of two groupsof muscles,superficial(gastrocnemius, oleus,plan-taris) and deep (tibialis posterior, flexor digitorumlongus, lexor hallucis longus),which are separatedby a fascial Iayer.

AI{TERIOR APPROACH TO THE TIBIALAAIDMARK AND INC/SIONLandmarkFor the surgeon, the subcutaneous swface of thetibia is the most accessible it of bone n the body.Unfortunately, this easeof accessmakes the boneattractive as a source of grafts. This procedureweakens he bone, something that is reflected n thehigh incidence of subsequent ractures.IncisisnThe longitudinal incision roughly parallels he linesof cleavage n the skin. The resultant scar is notunduly prominent, but often is visible in women be-causeof its position.SUPERFICIAL SURGICAL DISSECTIONThe periosteum of the tibia is a thick fibrous mem-brane that can be peeledoff the bone easily, espe-cially in children. Only lO% oI the blood suppiy ofthe bonecomes rom the periosteum;the remaining90% comes rom medullary vessels.Therefore, heperiosteumcan be elevatedoff a normal bonewith-out significant impairment of its blood supply. In

casesof fracture, however, soft-tissue attachmentsmay form the only remaining blood supply to iso-lated bone fragments and must be preserved.The long saphenousvein is the longest superfi-cial vein in the body. It originates iust distal andanterior to the medial malleolus and continuesproximally on the medial side of the leg superficialto the fascia. t may be ligated if necessary.DEEP SURGICAL DISSECTIONThetibialis anterior s the only muscle to arise romthe tibia in the anterior compartment (Fig. Il-241.The muscle may be avulsedpartially from the tibiain joggersandother athletes,and s one of the causesof shin splints. The pathologyof this particular com-plaint, however, s unclear.Somebelieve hat it resultsfrom stress ractures of the tibia itself; others con-tend that it representsa compartment syndrome.l0The common peronealnerve runs over he neckof the fibula in the substanceof the peroneusongusmuscleand divides nto deepand superficialbranches(Fig.1L-2s1.The deep peroneal netve continues to windaround the fibular neck deep to the extensordig-itorum longus muscle before reachingthe anterior


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Tibialis Anterior. Origin. Lateral condyle of tibia, uppertwo thirds of lateral surfaceof tibia, interosseousmem-brane, deep ascia,lateral intermuscular septum. Insertion. Medial cuneiform and base of first metatarcal.Ac-tron. Dorsiflexor and invertor of foot. Newe supply. Deepperonealnerve.ExtensorHallucis Longus. Origin. Middle half of anteriorsurfaceof fibula and interosseousmembrane. nsertion.Base f distal phalanxof hallux. Action. Extensorof halluxand ankle. Nerve supply. Deep peronealnerve.ExtensorDigitorum Longus. Origin. Upper three fourthsof anterior surface of fibula, small areaof. ibia adiacent osuperior tibiofibular joint, and interosseousmembrane.Insertion. Via extensorhoods to middle and distal pha-langesof lateral four toes.Action. Extensorof toes and ofankle. Nerve supply. Deep peronealnerve.PeroneusTertius. Origin. Lower third of anterior surfaceof fibula. Inseftion. Base of fifth metatarsal. Action.Evertor and dorsiflexor of foot. Nerve supply. Deep per-onealnerve.

surfaceof the interosseousmembrane. t runs downthe leg on the interosseousmembrane between hetibialis anterior and extensorhallucis longus mus-c1es, upplying all the muscles of the extensorpor-tion of the leg (seeFig. l1-25).The supe{icial peroneal nerve runs down theperonealcompartment of the leg, supplyingthe per-

Chapter 11 TheTibia U Fibula 503

oneus ongusand brevis muscles. ts dorsal cutane-ous branch supplies the skin on the dorsum of thefoot (see ig. 1-25).The anterior tibial aftery is a branch of thepopliteal artery.It reacheshe anteriorportion of theleg by passingabove he interosseousmembrane. tlies so close o the fibula that its venaecomitanres

Figure 11-24.compartment structures of the anteriorhe superficialof the leg.


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504 Surgiral Exposures n Orthopaedics: The Anatomic Approarh

Tendonof biceps emor isTibial is nter ior

CommonperonealExtensor igi torum ongus

Anter ior ib ia la,Peroneusongus

Superf ic ia l eroneal .Deepperonealn;

lnterosseousig a

Peroneus revisExtensor ig i torum ongus

Tib ia l is nter iorExtensor al luc is ongus

Anter ior ib iala:Deepperonealn:

InterosseousmembraneExtensor ig i torum ongus

Extensor al luc is ongus

often leave a notch in the bone large enough to bevisible on radiographs,a relationship that must berespectedwhen the fibular head s excised.The ar-tery runs with the deep peroneal nerve on the in-terosseousmembrane, it continues in the foot asthe dorsalispedis aftery (seeFig. 11-25).Three other muscles, the extensor hallucislongus, extensor digitorum longus, and peroneus

,"r..i\",\\iiii ,ii\! ! l l liili i t ti i i it l l ll l i il i i li i i ii l t !

l : li i t l

Patel larl igament

T ib ia ltuberc le

Me d ia lhead ofgastroc-n e m r u s

Medialsurfaceo f t i b i aSoleus

F ibu laFlexord ig i t o rumlongus

T ib ia l i sposter iorLateralm a l l e o l

i a l Medialm a l l eo lusm a l leo lus

Lateralmal leolu is ped isa.Peroneus ert i Deepperoneal .

Figure 11-25. Muscles of the anterior compartment have been resected o reveal theanlerior surface of the tibia, the neurovascular structures, the interosseous membrane,and the anterior surface of the fibula.

tertius, also occupy the anterior compartment ofthe leg. They are not involved in the anterior ap-proachto the tibia, but are part of the approach othe anterior compartment and may be seen duringthe exploration of wounds caused by open tibialfractures. Togetherwith the tibialis anterior mus-cle, they are implicated in the anterior compart-ment syndrome(seeFig. l1-25).

4 ^ l a ' l a


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Chapter 1I The Tibia U Fibula 505POSTEROLATERALAPPROACH TO THE TIBIA/NCIS/ONThe longitudinal incision almost parallels he linesof cleavagen the skin, and the resultant scar s notunduly broad. Cosmesisrarely is a problem withthis exposur; t is reservedargely for casesn whichthe skin on the anterior aspectof the tibia is unsui-table for surgery.

SUPERFICIAL SURGICAL DISSECTIONSuperficial surgical dissection consists of findingthe plane that separates he gastrocnemius andsoleus muscles from the peroneusbrevis muscle(seeFig. II-291.The fibers of the gastrocnemius are arrangedgenerally longitudinally, giving the muscle the abil-ity to contract a considerabledistance at the ex-penseof muscle strength.The gastrocnemiuscrossestwo joints. During quiet walking, plantar flexion ofthe ankle is carriedout largely by the powerful so-leus muscle,which crossesonly one oint. The gas-trocnemius is capable of acting as a fast plantarflexor of the ankle, but only if the soleus providespo-wer o overcome the inertia of the body weight.The gastrocnemius, therefore, comes into pl"ymainly during running and iumping.The major surgical importance of the soleusmuscle lies in the numerous plexuses of smallveins that it contains. This multipinnate muscleis one of the major pumps involved in venous re-turn from the limb; lack of muscular action (ie,after surgery or fractures) may lead to venousstasisand thrombosis.The percneus brevis tendon, which grooves hebackof the lateral malleolus, s useful n reconstruc-tion of the lateral side of the ankle.On occasion, heperoneusbrevis may avulse the styloid processofthe fifth metatarsal in associationwith inversioniniuries of the ankle {Fig.1l-26, seeFig. lL-291.

DEEP SURGICAL DISSECTIONP".p surgical dissection consistsof detachingtheflexor hallucis longus muscle from the fibula andthe tibialis posteriormuscle from the interosseousmembrane. Some fibers of the flexor digitorumlongusmuscle also must be reflectedoff the poster-ior surfaceof the tibia to permit accesso that bone.Generally, the dissection is carried out sub-

The flexorhallucis longusmusclehelpssupportthe longitudinal arch of the foot. In the sole ofthefoot, it sendsslips to the flexors of the secondandthird toes. It is muscular down to the level of theankle joint, a characteristic that makes it identifia-ble at that level.DAAIGERSNeraesand VesselsThe posterior tibial aftery and the tibial nerve liesuperficial (posterior) to the plane of dissection;they may be damaged if the appropriate surgicalplane is not adhered o.The posteriortibial attety, a branch of the pop-liteal artery, runs under the fibrous arch of the so-leus muscle. Its major branch in the calf is the per-oneal artery.The tibial nerve, he medial portion of the scia-tic nerve,enters he calf deepunder the fibrous archof the soleus muscle. It sendsbranches o all themusclesof the flexor compartment. Passingbehindthe medial malleolus, t divides nto threebranches:a calcanealbranch, a small lateral plantar nerve/and, finally, a larger medial plantar nerve (seeFig. 1L-271.

APPROACH TO THE FIBULALANDMARKS AND INCISIONLand:marks

sion. The shaft of the fibula is enclosed n muscles

and s palpableonly asa resistance elt on the lateralside of the leg.IncisionThe longitudinal incision closely parallels the lineof cleavagen the skin, and the resultant scar s notbroad and unsightly. As is true for the tibia, inci-sionsmade directly over the lower and upper endsof


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506

Medial head ofg a s t ro c n e m iu s

SurgbalExposuresn Orthopaedics:heAnatomirApproafi

monperoneal .Medial uralcutaneous .Smal lsaphenous .

Lateralhead ofgastrocnemiusPeroneuslongus

Soleus

Soleus

brevisPeroneuslongus

xor ha l luc islongusMediam a l leo lus arteryLateralm a l l eo lus

Calcaneus

the bone should be closed with special care to en-sure sound primary healing.SUPERFICIAL SURGICALDI SSECTIONSuperficial surgical dissection consists of mobiliz-ing the common peronealnerve as t winds aroundthe neck of the fibula and developingaplanebetweenthe peroneusand soleus muscles (Fig. I I-291.

Figure 11-26. The superficialstructuresof the pos-terolateral aspectof the leg.Gastrocnemius. Origin. Medial head from medialcondyleand popliteal surfaceof femut Lateralheadfrom lateral surfaceof lateral femoral condyle.Mid-dle third of posterior aspect. nsertion. Calcaneus.Into Achilles tendon with soleusand plantaris mus-cles.Achilles tendon then inserts nto calcaneus.Ac-tion. Plantar flexor of foot. Nerve supply. Tibialnerve.Soleus.Origin. Posterior aspect of upper third offibula, soleal ine on tibia, fibrous archbetween ibiaand ibula.Inseftion Middle third of posterioraspectof calcaneus. Common tendon with gastrocnemius.!Action. Plantar flexor of foot. Nerve supply. Tibialnerve.The common peronealnerve is the lateral por-tion of the tibial nerve; it is palpableat the neck ofthe fibula (Fig.11-30).

DEEP SURGICAL DISSECTIONDeep surgical dissection consists of stripping offthose muscles that originate from the fibula: theperoneus ongus and peroneusbrevis (lateral com-

ea l


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Chapter 11 The Tibia U Fibula 507

om m onperoneal .Lateralheadofgastrocnemius

neusl ongusPeroneal .

F lexorha l luc islongus

Medialheadofgastrocnemius

T ib ia l i sposterior

Posteriort i b ia l .

Figure 11-27, The gastrocnemius and soleus mus-cles have been resected o reveal he deep lexor com-partment and the neurovascularstructures.Flexot Hallucis Longus. Origin. Lower two thirds ofposteriorsurfaceof fibula, interosseousmembrane. n-sertion.Baseof distal phalanxof hallux. Action. Flexorof hallux andplantar flexor of foot. Newe supply. Tibialnerve.Flexor Digitorum Longus. Origin. Posteriorsurfaceofmiddle half of tibia and fascia covering ibialis poste-rior Insertron. Distal phalangesof lateral four toes.Action. Flexor of toes and dorsiflexor of foot. Nervesupply. Tibial nerve.

partment); the extensordigitorum longus,peroneustertius, and extensorhallucis longus (anteriorcom-partment); and the flexor digitorum longus, flexorhallucis longus,and soleus posteriorcompartment;seeFigs. LI-25 and 11-30).The peroneal afiery arises from the posteriortibial artery soon after t leaves he popliteaLartery.

T ib ia ln :

F lexor Peroneus revisd ig i t o rumlongus

Medialm a l l eo lus Peroneal .teralm a l l eo lus

Relatively small, it runs through the deep flexorcompartment of the leg, close to the fibula. Itsbrancheswind around the fibula to supply the per-oneus longus muscle. The artery is close to themedial surfaceof the lower end of the fibula and maybe damaged during operationson that part of thebone (seeFig. LI-271.


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508 Surgiral Exposures n Orthopaedics: The Anatomir Approach

Popl i teusSoleal ine

Flexordigi torumlongus

T ib ia

Flexordigi torumlongus

Ach i l l estendon

Me dm al leo lus

Lateralm a l l eo lus

SPECIAL AT{ TIOMICPOINTSCompartment SyndrorneThe muscles of the leg are enclosed n tight fibro-osseous ompartments.The fascial ayersare oughand unyielding, and swelling within a particularcompartment rapidly increasespressure.Pressure,

oneusbrevis

neala.l ra l mal leolus

Figure 11-28. The flexor hallucislongus, the tibialis posterior, and theflexor digitorum longus have been re-sected o reveal the posterioraspect ofthe fibula, interosseousmembrane,andtibia.Tibialis Posterior.Origin. Lateral side ofposterior aspect of tibia, upper twothirds of medial surface of fibula, inter-osseous membrane. Insertion. Tuber-osity of navicular and via ligaments toall cuneiforms; second, third, andfourth metatarsals;and cuboid and sus-tentaculum tali. Action. Plantar flexorand nvertor of foot. Nerve supply. Tibialnerve.

in turn, leads o venousstasis,still more intercom-partmental pressure/and, eventualty, arterial isch-emia. Increasing pressure alter fractures occursmost commonly in the anterior compartment, evenwhen the fracture s minor and not displaeed, ossi-bly because he fascia s so tight.The fascial layers define four distinct muscle

Me d ia l head ofg a s t ro c n e m iu sLateral head ofg a s t ro c n e m iu s

lantarisT ib ia l .

roneus ongusleus

T ib ia l .s ter ior ib ia la.

Peroneal .Flexorhal luc islongus

lnterosseousmembraneibu la

Flexorha l luc islongus

mon peroneal .


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Chapter 1I The Tibia U Fibula

l l i o t i b ia l and

ib ia l i santer iorExtensord ig i t o rumlongus

Peroneuslongus

roneusbrevis

509

Commonperoneal .Lateralheadofgastrocnemius

Figure 11-29. The superficialstructuresof the lateral aspectof the leg. F lexo r a l l uc i slongus

Achi l les endonLateralmal leolusPetoneusBrevis. Origin. Lower two thirdsof lateral aspectof fibula. Insertion.Baseoffifth metatarsal.Action. Evertorand plan-tar flexor of foot. Nerve supply. Superficialperonealnerve.

Peroneus Longus. Origin. Lateral tibialcondyle, upper two thirds of lateral surfaceof fibula. Insefiion. Lateral side of medialcuneiform and baseof first metatarsal.Ac-tion. Evertor and plantar flexor of foot.Nerve supply. Superficial peroneal nerve.

_ The compartment most commonly affected sthe anterior compartment. It can be decompressedby inci-sing_thedeep ascia that covers t albng itsentire length.All compartments of the leg may be decom-pressedby excision of the fibula.


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5 1 0 SurgbalExposuresn Orthopaedirs: heAnatomirApproafi

Headof f ibu la Lateralhead ofgastrocnemi

Commonperoneal :

F ibu la

T ib ia ltuberc le

Soleus

T ib ia

Tib ia l uberc le

Peroneusongus

uperf c ialperoneal .

Extensord ig i t o rumongusF ibu la

Flexha l l uc i slongus

PeroneusbrevisTendonofperoneus ongus

Lateralmal leolusTalus

Lateralm a l l eo lusCalcaneus

Figure 11-t0. The peronealmuscles have been resectedand the soleus and flexordifitorum longushavebeendetached artially from the origin to expose he lateralaspectof the fibula.


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Chapter 1I The Tibia Ll Fibula 5 1 1Rcferences

l .2.3.4.

5.

Muurn ME, AncoweRM, Wu,r,rNrcceRH:Manualof lnter-nal Fixation. New York, Springer-Verlag,1970Pnnutsren DB: Tieatment of ununited fractures by onlaybonegraftswithout screw or tie fixation and without break-ing down of the fibrous union. I Bone oint Surg29:946, 1947PerrtnsoN D, Lrwrs GN, Cess CA: Clinical experience nAustralia with an implanted bone growth stimulator11976-1978).Orthopaedic Tianscripts 3:288, 1979Henmox PH: A simplified surgicalapproach o the posteriortibia for bone grafting and fibular transference. Bone ointSvg27:496, 1945|oNEsKG, BanuEn HC: Cancellous-bonegrafting for nonu-nion of the tibia through the postero-lateralapproach. Bonefoint Surg Am] 37:1250,1955

HnrunyAK: Extensile Exposure,2nded. London, ChurchillLivingstone, 1973

SotrNsor.rKH: Treatment of delayedunion and nonunion ofthe- tibia by fibular resection. Acta Orthop Scand 40:9i,1959LEecHRE, HauuoNo G, Srrurrn WS: Anterior tibial com_part-nent syndrome:Acute and chronic. I Bone oint Surg[Am] 49:451,1967

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11 Tibia & Fibula(a)

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