Ankle/Foot Approaches Flashcards
position for anterior approach to ankle
supine
exsanguinate
tourniquet
incision for anterior approach to ankle
15 cm longitudinal incision over anterior aspect of the ankle joint from 10 cm proximal to 5 cm distal
internervous plane for anterior approach to ankle
use the intermuscular plane between EHL and EDL
superficial dissection for anterior approach to ankle
incise deep fascia
cut extensor retinaculum
retract EHL medially with NV bundle
retract EDL laterally
extensor hallucis longus
extensor digitorum longus
superficial peroneal nerve
deep peroneal nerve and anterior tibial artery
deep dissection for anterior approach to the ankle
incised soft tissue
incise ankle joint capsule
dangers for anterior approach to ankle
cutaneous branches of superficial peroneal nerve
deep peroneal nerve
anterior tibial artery
position for approaches to medial malleolus
supine
exsanguinate
tourniquet
incisions for approaches to medial malleolus
anterior - 10 cm longitudinal curved with midpoint just anterior to the tip of the medial malleolus
posterior - 10 cm incision starting 5 cm above the ankle on the posterior border of the tibia curving forward behind the medial malleolus
internervous plane for approaches to medial malleolus
none. subcutaneous bone
superficial dissection for approaches to medial malleolus
ID long saphenous vein and nerve
anterior - deep dissection for approaches to medial malleolus
posterior - incise fascia over tibialis posterior
retract tib post anterior, the rest posterior
incise retinaculum
split deltoid ligament
dangers for approaches to medial malleolus
anterior - saphenous nerve, long saphenous vein
posterior - tom, dick and very nervous harry
both - vascularity of bone fragments
position for posteromedial approach to ankle
supine with hip and knee flexed and leg in external rotation
or
lateral with operative side down and other knee flexed and draped over
incision for posteromedial approach to ankle
8-10 cm longitudinal incision midway between medial malleolus and achilles
superficial dissection for posteromedial approach to ankle
incise fascia away from the posterior bundle of structures
deep dissection for posteromedial approach to ankle
3 options:
1) posterior to FHL
2) between FHL and the NV bundle
3) direct onto the Tom, Dick and Harry (only for lengthening
dangers for posteromedial approach to ankle
posterior tibial artery
tibial nerve
position for posterolateral approach to the ankle
prone
abdomen free
bump under operative leg
exsanguinate
tourniquet
incision for posterolateral approach to the ankle
10 cm longitudinal halfway between posterior border of lateral malleolus and lateral border of achilles
begin at tip of fibula and extend proximally
internervous plane for posterolateral approach to the ankle
peroneus brevis and FHL
superficial dissectionfor posterolateral approach to the ankle
short saphenous vein and sural nerve should be anterior to incision
incised deep fascia
ID peroneal tendons
develop plane between peroneals and FHL
fascia covering peroneal compartment
FHL
FHL
PITFL
transverse tibiofibular ligament
posterior talofibular ligament
deep dissection for posterolateral approach to ankle
incised lateral fibres of FHL from fibula and retract medially
dangers for posterolateral approach to ankle
short saphenous vein
sural nerve
position for the lateral approach to the lateral malleolus
supine
sandbag under buttock
tilt table away
exsanguinate
tourniquet
incision for the lateral approach to the lateral malleolus
10-15 cm longitudinal incision along posterior margin of fibula to 2 cm past its distal tip (centre at the level of the fracture
internervous plane for the lateral approach to the lateral malleolus
none really - unless you go much more proximal then it is between tertius and brevis
superficial dissection for the lateral approach to the lateral malleolus
avoid short saphenous vein and sural nerve (just posterior to lateral malleolus)
deep dissection for the lateral approach to the lateral malleolus
strip periosteally to retain blood supply of terminal branches of peroneal artery
dangers for the lateral approach to the lateral malleolus
sural nerve
terminal branches of peroneal artery lying on the medial surface of the distal fibula
position for anterolateral approach to ankle and hindfoot
supine
sandbag under operative leg buttock
exsanguinate
tourniquet
incision for anterolateral approach to ankle and hindfoot
15 cm slightly curved incision on anterolateral aspect of the ankle beginning 5 cm proximal to ankle joint and 2 cm anterior to the anterior border of fibula, end 2 cm medial to 5th metatarsal (over the 4th)
superficial peroneal nerve
extensor digitorum longus
tendon of peroneus tertius
sinus tarsi fat pad
AITFL
extensor retinaculum
internervous plane for anterolateral approach the ankle hindfoot
between peroneals and extensors
superficial dissection for anterolateral approach the ankle hindfoot
incise fascia
incise inferior and superior retinacula
ID and preserve dorsal cutaneous branches of superficial peroneal nerve
ID peroneus tertius and EDL
incise to bone just lateral to these muscles
AITFL
ATFL
EDB
deep dissection for anterolateral approach to the ankle and hindfoot
retract extensors medially
detach EDB from calcaneus
ID dorsal capsules of the calcaneocuboid and talonavicular joints (midtarsal joint)
ID fat in the sinus tarsi, clear it to expose the talocalcaneal joint
calcaneocuboid joint
talonavicular joint
dangers for anterolateral approach to the ankle and hindfoot
deep peroneal nerve
anterior tibial artery
position for lateral approach to hindfoot
supine
sandbad
table tilt
exsanguinate
tourniquet
incision for lateral approach to hindfoot
curved incision starting just distal and posterior to the tip of the lateral malleolus curving medially to end over the talcalcaneonavicular joint
internervous plane for lateral approach to hindfoot
peroneus tertius and peroneal tendons
superficial dissection for lateral approach to hindfoot
do not mobilize widely
ligate any veins
open deep fascia
retract tendons medially
deep dissection for lateral approach to hindfoot
detach fat pad partially
detach origin of EDB
reflect distally
access which joint you are interested in
access the posterior talocalcaneal joint by retracting the peroneals anteriorly
dangers for lateral approach to hindfoot
exposures here are notorious for skin necrosis
bifurcate ligament
position for lateral approach to posterior talocalcaneal joint
supine
sandbag
tilt table
exsanguinate
tourniquet
incision for lateral approach to the posterior talocalcaneal joint
10-13 cm on lateral aspect of ankle beginning 4 cm above tip of lateral malleolus on posterior border of fibula, then curve forward just under the peroneal tubercle on the lateral calcaneous
internervous plane for lateral approach to the posterior talocalcaneal joint
none
superficial dissection for lateral approach to the posterior talocalcaneal joint
ID short saphenous vein and sural nerve
incise fascia
uncover peroneal tendons
incise peroneal fascia
retract tendons anteriorly
incise joint capsule
deep dissection for lateral approach to the posterior talocalcaneal joint
ID calcaneofubular ligament
often need subperiosteal dissection from calcaneus to find the joint
dangers for lateral approach to the posterior talocalcaneal joint
sural nerve
position for lateral approach to calcaneus
lateral
operative leg posterior
exsanguinate
tourniquet
incision for lateral approach to calcaneus
2 limbs:
one from base of 5th metatarsal extending posteriorly along skin change line, second 6 to 8 cm above the heel skin halfway between the posterior aspect of the fibula and the lateral aspect of the Achilles. they meet in an L shape
internervous plane for lateral approach to calcaneus
none - direct to subcutaneous bone
superficial dissection for lateral approach to calcaneus
dissect straight down to the lateral surface of the calcaneus
deep dissection for lateral approach to calcaneus
incise periosteum on lateral wall of calcaneus and develop a full-thickness flap
divide calcaneofibular ligament to expose subtalar joint
dangers for lateral approach to calcaneus
sural nerve
soft tissue necrosis a risk
position for dorsal approach to mid-foot
supine
sandbag
exsanguinate
tourniquet
incision for dorsal approach to mid-foot
longitudinal incision directly over the from the first metatarsal-cuneiform joint to navicular tubercle to 1 cm distal to medial malleolus
internervous plane for dorsal approach to mid-foot
none - longitudinal incisions tend to spare cutaneous nerves, however, some may be sacrificed
dissection for dorsal approach to mid-foot
skin
avoid cutaneous nerves
aim for thick skin flaps
minimize retraction
avoid damaging insertions of inverters and everters
position for dorsomedial approach to MTP joint of great toe
supine
exsanguinate
tourniquet
incision for dorsomedial approach to MTP joint of great toe
begin just proximal to interphalangeal joint on dorsomedial aspect of great toe
curve over dorsal aspect of MTP joint
remain medial to tendon of EHL
then along medial shaft of 1st metatarsal
internervous plane for dorsomedial approach to MTP joint of great toe
none
2 tendons (EHL and AbH)
deep peroneal nerve
saphenous nerve
EHL
superficial dissection for dorsomedial approach to MTP joint
incise fascia
dorsal digital branch of medial cutaneous nerve protected laterally
U-shaped incision in joint capsule leaving it attached to proximal edge of proximal phalanx
deep dissection for dorsomedial approach to MTP joint
incise periosteum
strip coverings of bones
take care not to damage FHL tendon
danger for dorsomedial approach to MTP joint
tendon of EHL
tendon of FHL
Position for dorsal approach to the metatarsophalangeal joints (other than 1st)
supine
bolster under thigh on operative side
flex knee
incision for dorsal approach to the metatarsophalangeal joints (other than 1st)
2-3 cm longitudinal incision on dorsolateral aspect of affected MTP joint just lateral to the long extensor tendon
intervervous plane for dorsal approach to the metatarsophalangeal joints (other than 1st)
none
avoid the dorsal digital nerves
superficial dissection for dorsal approach to the metatarsophalangeal joints (other than 1st)
incise fascia medial to extensor tendon and retract the tendon laterally
deep dissection for dorsal approach to the metatarsophalangeal joints (other than 1st)
incise dorsal capsule of the MTP joint longitudinally to enter the joint
danger for dorsal approach to the metatarsophalangeal joints (other than 1st)
long extensor tendon
plantar nerves and vessels lie deep to transverse metatarsal ligament between the metatarsal heads
position for approach to the dorsal web spaces
supine
exsanguinate
tourniquet
sandbag under thigh
flex knee
incision for approach to the dorsal web spaces
dorsal longitudinal incision over centre of the webspace 2-3 cm from distal web space
internervous plane for approach to the dorsal web spaces
none
superficial dissection for approach to the dorsal web spaces
incise deep transverse metatarsal ligament in line with skin
expose neurovascular bundle
view neuroma
danger for approach to the dorsal web spaces
dorsal cutaneous nerve
take care to protect plantar neurovascular bundle