Dorsolateral approach to the midfoot

The dorsolateral approach is indicated for fractures of the lateral column. It is centered over the cuboid and can be extended distally to the base of the 4th metatarsal and proximally to the tip of the fibula.

Deep dissection in the dorsolateral approach to the cuboid

The following structures can be accessed through this incision:

3rd to 5th proximal metatarsals
3rd to 5th tarsometatarsal joints
Lateral cuneiform
Cuboid
Calcaneocubiod joint

Fractures addressed with the dorsolateral approach to the cuboid

Combination with the dorsomedial approach

This approach may be combined with the dorsomedial approach. In this case, it is crucial to keep a minimum of 5 cm distance between the two incisions to ensure the survival of the skin bridge.

Combination of the dorsomedial approach with the dorsolateral approach to the cuboid

To localize your incision, palpate the following anatomical points.
The sinus tarsi and distal calcaneus are palpable proximally. The base of the 4th and 5th metatarsals are palpable distally. The cuboid lies between those two areas.

Bony anatomical landmarks of dorsolateral approach to the cuboid

Key anatomical structures encountered in this approach are the following:

Extensor digitorum brevis (EDB)
Peroneus tendons
Sural nerve
Superficial peroneal nerve

Key anatomical structure in dorsolateral approach to the cuboid

Center the incision over the cuboid along the fourth metatarsal axis and proximally to the tip of the fibula.

Skin incision for a dorsolateral approach to the cuboid

Protect the sural nerve

Take care not to harm the dorsolateral or lateral sural nerve branches.

In a high-energy injury, the comminution may be severe. Take care not to strip the periosteum or joint capsule from any small pieces. If a piece is attached to a proximal piece of the joint capsule, then the best course of action may be to flip it proximally so as not to disrupt its soft-tissue attachments. Once the joint is reconstructed, this “trap-door” piece can be reduced and fixed.

Reflect the extensor digitorum brevis (EDB) muscle belly dorsomedially.

The peroneal muscles can be retracted towards the plantar aspect. The peroneal longus muscle belly crosses from superior laterally and goes under the cuboid in the peroneal groove on its course to the plantar base of the first metatarsal. The peroneus brevis inserts onto the base of the fifth metatarsal.

This exposes the cuboid.

The lateral cuneiform and base of 3rd to 5th metatarsals can be visualized in the intermuscular plane between the extensor digitorum brevis and the peroneal muscles distally.