What structures can get damaged during a proximal tibia fracture treated with plating through an anterolateral approach?

Structures at Risk During Proximal Tibia Fracture Plating via Anterolateral Approach

The superficial peroneal nerve is the primary structure at risk during proximal tibia fracture plating through an anterolateral approach, followed by the anterior tibial vessels and deep peroneal nerve.

Anatomical Structures at Risk

Primary Neurovascular Structures at Risk

• Superficial Peroneal Nerve (SPN)

  • Consistently found in the subcutaneous tissues during the distal incision 1
  • Demonstrates variable anatomy, exiting the lateral compartment crural fascia at an average of 11.6 cm from the tip of the lateral malleolus 2
  • At risk for injury during percutaneous plating techniques 2

• Deep Peroneal Nerve and Anterior Tibial Vessels (DPN/ATV)

  • Course along the posterior half of the tibial shaft proximally 1
  • Cross the distal third of the plate as they transition to an anterior position 1
  • Consistently cover the tibia in a region 40 to 110 mm proximal to the ankle joint 1
  • At high risk during plate placement from distal to proximal along the anterolateral border 1

Secondary Structures at Risk

• Saphenous Nerve and Vein
  • While not directly in the anterolateral approach path, these structures are at risk during medial approaches
  • Follow a predictable course along the medial aspect of the ankle 2
  • Injury typically occurs 2.0 to 4.7 cm from the tip of the medial malleolus during percutaneous techniques 2

Risk Factors and Anatomical Considerations

• Plate Positioning

  • The deep peroneal nerve and anterior tibial vessels cross from a posterior to anterior position in the distal third of the tibia 1
  • This transition zone creates a high-risk area for iatrogenic injury during plate placement

• Surgical Approach

  • Direct anterolateral approaches are safer than posterior or posterolateral approaches for accessing the proximal tibia 3
  • Modified anterolateral approaches can be used for reduction and fixation of posterolateral fracture fragments 3

• Percutaneous Techniques

  • Percutaneous plating techniques increase the risk of neurovascular injury compared to open approaches 2
  • Careful dissection is required proximally for fibular plating and distally for tibial plating to minimize risk 2

Prevention Strategies

• Anatomical Knowledge

  • Understanding the variable course of the superficial peroneal nerve is crucial
  • Recognize that the nerve exits the lateral compartment at different points (average 11.6 cm from lateral malleolus) 2

• Surgical Technique

  • Direct visualization of the superficial peroneal nerve during the distal incision 1
  • Careful soft tissue handling and protection of identified neurovascular structures
  • Consider using blunt dissection in high-risk areas

• Approach Selection

  • Modified anterolateral approaches may provide safer access for specific fracture patterns 3
  • For complex bicondylar tibial plateau fractures, consider dual incision approaches rather than extensive single incisions 4

Clinical Implications of Neurovascular Injury

• Nerve Injury Sequelae

  • Superficial peroneal nerve injury: sensory deficits along the dorsum of the foot
  • Deep peroneal nerve injury: foot drop and sensory loss in the first web space

• Vascular Injury Consequences

  • Anterior tibial vessel injury may compromise distal circulation
  • May lead to delayed healing or non-union in severe cases

• Functional Outcomes

  • Nerve injuries can significantly impact functional outcomes and quality of life
  • May require additional surgical interventions or prolonged rehabilitation

By understanding the anatomical relationships and employing careful surgical techniques, the risk of neurovascular injury during anterolateral plating of proximal tibia fractures can be minimized, leading to improved patient outcomes.