lower limb approaches

Question 1

ilioinguinal approach

Answer 1

Indications:
- anterior column, anterior wall
- indirect articular reduction

Position
* supine
* sandbag under ipsilateral buttock
* catheter to empty bladder
* c-arm positioned for obturator/ iliac oblique, inlet and outlet views

landmarks
- ASIS to pubic tubercle

Skin incision
- curved incision from iliac crest
- 5cm superior to ASIS extending medially to pubic symphysis

superficial:
- divide aponeurosis of external oblique inline with fibres
- protect round ligament and spermatic cord (sling)
- medially - rectus sheath divided - expose rectus abdominus
- laterally - incise periosteum, release abdominal and iliacus muscle insertions off ilium
- subperiosteally elevate iliacus off internal iliac fossa

Deep:
Three operative windows developed
- medial - medial to femoral vessels - pubic symphysis
- middle - lateral to femoral vessels and medial to iliopsoas - pelvic brim and quadrilateral plate
- lateral - lateral to iliopsoas - ilium

Dangers
- femoral nerve/ vessels
- lateral femoral cut nerve
- obturator artery/ vessels
- inferior epigastric vessels
- bladder
- spermatic cord

Question 2

smith-peterson - anterior hip approach

Answer 2

Indications
- washout hip
- intracapsular nof fixation
- anterior hip reduction

position
- supine
- externally rotate leg - stretches sartorius and capsule

Internervous plane
- superior gluteal nerve
- femoral nerve

incision
- ant half iliac crest
- ASIS
- vertically 10cm

superficial
- skin, fat and deep fascia
- sartorius medially and TFL laterally
- ligate ascending branch of lat circumflex femoral artery

Deep
- rectus femoris (fem nerve) and gluteus medially
- rectus femoris origin can be detached
- capsulotomy

Dangers
- LFCN - reduced lat sensation or painful neuroma
- ascending branch of lateral femoral circumflex artery

Question 3

posterolateral ankle approach

Answer 3

skin incision
- longitudinal
- between achilles and fibula

Dissection
- skin, fat, deep fascia
- FHL (tibial nerve) medially and peroneals (superficial peroneal nerve) laterally

Danger
- sural nerve - neuroma
- short saphenous vein

Question 4

sural nerve anatomy and innervation

Answer 4

• branches of tibial nerve and common peroneal
• sensory - lateral aspect of foot