Fibula – Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The lateral approach to the fibula is the gold standard for open reduction and internal fixation of fibular shaft fractures, especially distal and proximal segments. It offers excellent visualization of the fibula while enabling safe identification and protection of the common peroneal nerve (CPN). This approach remains fundamental in trauma and reconstructive surgery, although minimally invasive and percutaneous techniques are increasingly favored for select distal fibular fractures.

Applied Anatomy & Intervals

Internervous Interval

Between the superficial peroneal nerve (SPN) laterally (innervating peroneal muscles) and the tibial nerve medially (innervating the flexor compartment).

Anatomic Landmarks

• Head of fibula (palpable lateral knee prominence)
• Lateral malleolus (distal fibular tip)
• Posterior border of biceps femoris tendon (near fibular head)

Patient Positioning & Setup

• Table Type: Standard radiolucent operating table
• Patient Position: Supine with a sandbag or bump under the ipsilateral buttock to slightly internally rotate the leg; lateral decubitus position is an alternative for proximal fibular exposure
• Specialized Equipment:
• Limb positioner or bump to maintain knee flexion and leg stability
• C-arm fluoroscopy positioned for anteroposterior (AP) and lateral views of the fibula

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

• Longitudinal incision just posterior to the fibula, extending from distal to lateral malleolus proximally to the fibular head
• Incise fascia overlying the peroneal muscles

Deep Dissection & Exposure

• Identify the posterior border of the biceps femoris tendon near the fibular head
• Locate and carefully dissect the common peroneal nerve (CPN) as it winds around the fibular neck; gently mobilize it from its groove
• Develop the interval between the peroneus longus and soleus muscles
• Longitudinally incise the periosteum and elevate it subperiosteally
• Subperiosteally strip the interosseous membrane from proximal to distal to fully expose the fibular shaft

The “Danger Zone”

Post-Operative Pearl

Early mobilization with protected weight-bearing is generally allowed unless contraindicated by associated injuries. Avoid aggressive knee flexion or varus stress early postoperatively to protect the common peroneal nerve and maintain soft tissue integrity.

Classic Clinical Notes

Fibula – approach

• Position: Supine with sandbag under buttock or lateral
• Incision: Long incision just posterior to fibula beginning behind lateral malleolus and extending to level of fibular head
• Internervous plane: Peroneal muscles (SPN) & flexor muscles (tibial nerve)
• Dissection:
• Find posterior border of biceps femoris as it sweeps down past knee before inserting on head of fibula
• Incise fascia & identify common peroneal nerve (CPN)
• Trace course of CPN as it winds around fibular neck
• Mobilize CPN from groove on back of neck
• Develop plane between peroneus longus (PL) & soleus
• Incise periosteum of fibula
• Strip muscle off fibula
• Strip interosseous membrane subperiosteally from proximal to distal
• Dangers:
• CPN – winds around neck of fibula
• Dorsal cutaneous branch of SPN – identify at junction of distal & middle 1/3 of fibula
• Peroneal artery – terminal branches lie close to deep surface of lateral malleolus
• Lesser saphenous vein

Last Updated on January 25, 2026 by orthonet