Muscles Exposed During Medial Malleolus Fracture ORIF
During a medial malleolus fracture ORIF procedure, the primary muscles exposed include the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles.
Surgical Approach for Medial Malleolus ORIF
Direct Medial Approach
The standard approach for medial malleolus fractures involves a direct medial incision centered over the medial malleolus. This approach exposes:
- Tibialis Posterior: This muscle is the most anterior of the three deep posterior compartment muscles and is directly visualized during the approach
- Flexor Digitorum Longus: Located posterior to the tibialis posterior
- Flexor Hallucis Longus: The most posterior of the three muscles, often requiring retraction during the procedure 1
Anatomical Considerations
When performing the direct medial approach:
- A longitudinal incision of approximately 10 cm is centered directly over the medial malleolus
- The incision is deepened straight down to the bone
- The periosteum is identified over the distal tibia
- Careful subperiosteal dissection provides access to the posterior aspect of the medial malleolus 1
Neurovascular Safety
- The neurovascular bundle (posterior tibial artery and tibial nerve) is located approximately 2.64 cm from the center of the medial malleolus 1
- A periosteal sheath should be developed during dissection to protect these structures
- The sural nerve and peroneal artery must also be protected, especially when using posterior approaches 2
Alternative Approaches
Posterolateral Approach
When addressing associated posterior malleolus fractures, a posterolateral approach may be used:
- The incision is made dorsally to the peroneal tendons
- The superficial and deep fascia are incised
- The flexor hallucis longus tendon is retracted medially to visualize the posterior malleolus 3
Percutaneous Techniques
For minimally displaced fractures or patients with fragile soft tissues:
- Percutaneous fixation techniques can be employed
- These approaches minimize soft tissue dissection but still require awareness of the underlying musculature 2, 4
Surgical Considerations
Positioning
- For isolated medial malleolus fractures: supine position
- For combined posterior and medial malleolus fractures: may require repositioning from lateral to supine during the procedure 3
Soft Tissue Handling
- Careful retraction of the flexor tendons is essential to prevent tendon injury
- The periosteum should be handled meticulously to facilitate proper healing 1
Fixation Methods
- Plate and screw fixation or tension band wiring are common fixation methods
- The choice depends on fracture pattern and bone quality 5
Post-Operative Protocol
Following ORIF of medial malleolus fractures:
- Six weeks of partial weight bearing (20 kg)
- Early functional exercises, particularly of the flexor hallucis longus muscle
- Transition to full weight bearing after clinical and radiological follow-up at 6 weeks 3
Understanding the muscular anatomy during medial malleolus ORIF is crucial for proper exposure, protection of vital structures, and achieving optimal surgical outcomes.