Approach - more detail

Midfoot - Midfoot, intertarsal fractures

Medial utility incision to the navicular
Indications
The medial utility incision can be used to approach any of the medial structures of the foot, including tendons, joints and bones.
The incision can potentially extend from the great toe along the medial column to the back of the talus. Most often, we use only a portion of the overall length of this approach.
Anatomy
The medial utility incision is in a safe plane between the posterior tibialis and the anterior tibialis. There are no major neurovascular structures in this region. Superficial small
veins can be cauterized during the approach.
Skin incision
For the medial approach to the navicular, the area along the medial utility incision over the navicular is used. The incision can be extended proximally to allow access to the
talonavicular joint, or distally for access to the cuneiforms, first metatarsal base and naviculo-cuneiform and intertarsal joints.
The anterior tibialis tendon can be found at its insertion on the medial cuneiform or the base of the first metatarsal. The master knot of Henry can be found plantar to the
cuneiform, where the flexor digitorum longus (FDL) and flexor hallucis longus (FHL) cross.
Additional dorsomedial incision
 If there is a navicular fracture with comminution and loss of the architecture of the navicular part of the talo-navicular joint, then a dorsomedial incision may be used to properly
reconstruct the shape of the navicular.
If fracture care requires a more extensile approach, the advantages of better reduction are balanced against wider dissection causing stripping/loss of blood supply which may
impede healing. If the dorsomedial approach is required, care should be taken to minimize dissection.
For details of the dorsomedial approach, click here .
Closing the dead space
The medial utility incision can be closed in layers. A few deep stitches here can close the plantar medial space that may have resulted from the dissection, especially where the
master knot has been approached. This should be done with great care in order to prevent development of a foot compartment syndrome.

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v1.0 2010-10-14