# Abordajes del tobillo: 5 corredores, 4 nervios y 3 decisiones de planificación — guion de ponencia

*Guion de ponencia de 10 minutos · Dr. Anthony Cevallos · Biblioteca Traumatología y Ortopedia · https://t.cescac.com/tema/abordajes-tobillo/ · actualizado el 10 de octubre de 2026*

> Material educativo para profesionales y estudiantes de medicina; no reemplaza el juicio clínico, las guías institucionales ni la supervisión del tutor.

## Guion (10 minutos)

Lámina 1 (0:30): Título, objetivo y aviso: material educativo; no sustituye al juicio clínico, a las guías institucionales ni a la supervisión del tutor.

Lámina 2 (1:00): El mapa de 5 corredores y las 3 preguntas previas a cada incisión: qué fragmento, qué nervio, qué piel [r1][r3][r2][r38][r4].

*Fuentes de esta lámina:* [r1] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r2] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r3] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r4] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r38] AO Foundation. En: AO Surgery Reference [Internet]. 2026.

Lámina 3 (1:30): Los nervios que no perdonan: peroneo superficial y sus 3 patrones, sural con cruce de 2,7 a 4,5 cm en 22 de 28, safeno a 8 mm de la punta, peroneo profundo con la tibial anterior [r6][r8][r27][r5].

*Fuentes de esta lámina:* [r5] Lawrence SJ et al. Foot Ankle Int. 1995. doi:10.1177/107110079501601110; [r6] Blair JM et al. Clin Orthop Relat Res. 1994. PMID 8050234; [r8] Ghani Y et al. J Foot Ankle Surg. 2023. doi:10.1053/j.jfas.2022.08.001; [r27] Mercer D et al. Iowa Orthop J. 2011. PMID 22096447

Lámina 4 (1:30): Lateral y medial paso a paso: incisión, plano, nervio y dónde va la placa [r1][r3][r37].

*Fuentes de esta lámina:* [r1] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r3] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r37] Deng Y et al. Foot Ankle Int. 2022. doi:10.1177/10711007221079617

Lámina 5 (1:30): Posterolateral frente a posteromedial modificado: 99 % frente a 64 % de exposición en cadáver, tracción del haz y qué dice la clínica [r15][r29][r56][r57].

*Fuentes de esta lámina:* [r15] Meulenkamp B et al. OTA Int. 2019. doi:10.1097/OI9.0000000000000021; [r29] Assal M et al. J Orthop Trauma. 2017. doi:10.1097/BOT.0000000000000774; [r56] Zhong S et al. Orthop Surg. 2017. doi:10.1111/os.12308; [r57] Khandge A et al. Cureus. 2024. doi:10.7759/cureus.69402

Lámina 6 (1:00): Anterolateral y anteromedial del pilon, puentes cutáneos y la regla de 7 cm [r51][r10][r18].

*Fuentes de esta lámina:* [r10] Howard JL et al. J Orthop Trauma. 2008. doi:10.1097/BOT.0b013e318172c811; [r18] AO Foundation. En: AO Surgery Reference [Internet]. 2026.; [r51] AO Foundation. En: AO Surgery Reference [Internet]. 2026.

Lámina 7 (1:00): Posición y orden: prono, supino o lateral; el borde posterior y la sindesmosis [r21][r9][r68].

*Fuentes de esta lámina:* [r9] Simske NM et al. J Am Acad Orthop Surg. 2024. doi:10.5435/JAAOS-D-23-00577; [r21] Miller MA et al. Foot Ankle Int. 2018. doi:10.1177/1071100717735839; [r68] Behery OA et al. Iowa Orthop J. 2021. PMID 34552413

Lámina 8 (1:00): Momento quirúrgico: NICE y 2 metaanálisis que discrepan; pilon por etapas [r11][r12][r13][r19].

*Fuentes de esta lámina:* [r11] National Institute for Health and Care Excellence. NICE guideline NG38 [Internet]. 2016.; [r12] Edelstein A et al. Arch Orthop Trauma Surg. 2025. doi:10.1007/s00402-025-05896-8; [r13] Farhan-Alanie MM et al. Acta Orthop Belg. 2025. doi:10.52628/91.3.12971; [r19] Sirkin M et al. J Orthop Trauma. 1999. doi:10.1097/00005131-199902000-00002

Lámina 9 (0:30): Caso didáctico y preguntas para la discusión.

Lámina 10 (0:30): Mensajes para llevarse y referencias.

## Mensajes clave

- Cada corredor tiene su nervio: se busca, no se supone [r1][r2][r3].
- El fragmento posterior decide el corredor posterior: la TC, no el porcentaje, define si va por posterolateral o posteromedial [r16][r15][r14].
- La piel decide cuándo y por dónde: puentes sin socavar, colgajos de espesor completo y etapas en el pilon [r18][r19].
- El prono y el abordaje posterior mejoran la visión del borde posterior pero tienen costo nervioso: elige con el caso en la mano [r21][r9].

## Referencias

- **[r1]** AO Foundation. Lateral approach to the malleoli. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/lateral-approach <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/lateral-approach>
- **[r2]** AO Foundation. Posterolateral approach to the Volkmann fragment. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/posterolateral-approach-to-the-volkmann-fragment <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/posterolateral-approach-to-the-volkmann-fragment>
- **[r3]** AO Foundation. Medial approach (anterior) to the malleoli. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/medial-approach-anterior <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/medial-approach-anterior>
- **[r4]** AO Foundation. Anterolateral approach to the distal tibia. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anterolateral-approach-to-the-distal-tibia <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anterolateral-approach-to-the-distal-tibia>
- **[r5]** Lawrence SJ, Botte MJ. The deep peroneal nerve in the foot and ankle: an anatomic study. Foot Ankle Int. 1995;16(11):724-8. doi:10.1177/107110079501601110. <https://doi.org/10.1177/107110079501601110>
- **[r6]** Blair JM, Botte MJ. Surgical anatomy of the superficial peroneal nerve in the ankle and foot. Clin Orthop Relat Res. 1994;(305):229-38. <https://pubmed.ncbi.nlm.nih.gov/8050234/>
- **[r8]** Ghani Y, Najefi AA, Aljabi Y, Vemulapalli K. Anatomy of the Sural Nerve in the Posterolateral Approach to the Ankle: A Cadaveric Study. J Foot Ankle Surg. 2023;62(2):286-290. doi:10.1053/j.jfas.2022.08.001. <https://doi.org/10.1053/j.jfas.2022.08.001>
- **[r9]** Simske NM, Kotchman H, Pennacchio C, Dorney I, Vallier HA. Frequent Sural Nerve Injury with Posterior Approach for Ankle Fracture Fixation. J Am Acad Orthop Surg. 2024;32(16):747-753. doi:10.5435/JAAOS-D-23-00577. <https://doi.org/10.5435/JAAOS-D-23-00577>
- **[r10]** Howard JL, Agel J, Barei DP, Benirschke SK, Nork SE. A prospective study evaluating incision placement and wound healing for tibial plafond fractures. J Orthop Trauma. 2008;22(5):299-305. doi:10.1097/BOT.0b013e318172c811. <https://doi.org/10.1097/BOT.0b013e318172c811>
- **[r11]** National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. NICE guideline NG38 [Internet]. London: NICE; 2016 [consultado 2026 oct 10]. Recomendación 1.4.2. Disponible en: https://www.nice.org.uk/guidance/ng38/chapter/Recommendations <https://www.nice.org.uk/guidance/ng38/chapter/Recommendations>
- **[r12]** Edelstein A, McDonald J, Lee W. The impact of surgical timing in ankle fracture on postoperative wound complications: a critical 24-hour cutoff point through systematic review and meta-analysis. Arch Orthop Trauma Surg. 2025;145(1):269. doi:10.1007/s00402-025-05896-8. <https://doi.org/10.1007/s00402-025-05896-8>
- **[r13]** Farhan-Alanie MM, Sahemey R, Al-Hourani K, Trompeter A. Impact of timing of surgery on wound complications and re-operations following closed ankle fracture fixation: a systematic review and meta-analysis. Acta Orthop Belg. 2025;91(3):325-340. doi:10.52628/91.3.12971. <https://doi.org/10.52628/91.3.12971>
- **[r14]** Wang X, Ma X, Zhang C, Huang J, Jiang J. Anatomical factors affecting the selection of an operative approach for fibular fractures involving the posterior malleolus. Exp Ther Med. 2013;5(3):757-760. doi:10.3892/etm.2012.872. <https://doi.org/10.3892/etm.2012.872>
- **[r15]** Meulenkamp B, Louati H, Morellato J, Papp S, Lalonde KA. Posterior malleolus exposure. OTA Int. 2019;2(2):e021. doi:10.1097/OI9.0000000000000021. <https://doi.org/10.1097/OI9.0000000000000021>
- **[r16]** Hunt AA, Maschhoff C, Van Rysselberghe N, Gonzalez CA, Goodnough H, Gardner M, et al. Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now? Injury. 2024;55(6):111537. doi:10.1016/j.injury.2024.111537. <https://doi.org/10.1016/j.injury.2024.111537>
- **[r18]** AO Foundation. Anteromedial approach to the distal tibia. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anteromedial-approach-to-the-distal-tibia <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anteromedial-approach-to-the-distal-tibia>
- **[r19]** Sirkin M, Sanders R, DiPasquale T, Herscovici D. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13(2):78-84. doi:10.1097/00005131-199902000-00002. <https://doi.org/10.1097/00005131-199902000-00002>
- **[r21]** Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, et al. Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation. Foot Ankle Int. 2018;39(1):99-104. doi:10.1177/1071100717735839. <https://doi.org/10.1177/1071100717735839>
- **[r27]** Mercer D, Morrell NT, Fitzpatrick J, Silva S, Child Z, Miller R, et al. The course of the distal saphenous nerve: a cadaveric investigation and clinical implications. Iowa Orthop J. 2011;31:231-5. <https://pubmed.ncbi.nlm.nih.gov/22096447/>
- **[r29]** Assal M, Dalmau-Pastor M, Ray A, Stern R. How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches. J Orthop Trauma. 2017;31(4):e127-e129. doi:10.1097/BOT.0000000000000774. <https://doi.org/10.1097/BOT.0000000000000774>
- **[r37]** Deng Y, Staniforth TL, Zafar MS, Lau YJ. Posterior Antiglide Plating vs Lateral Neutralization Plating for Weber B Distal Fibular Fractures: A Systematic Review and Meta-analysis of Clinical and Biomechanical Studies. Foot Ankle Int. 2022;43(6):850-859. doi:10.1177/10711007221079617. <https://doi.org/10.1177/10711007221079617>
- **[r38]** AO Foundation. Posteromedial approach to the malleoli. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/posteromedial-approach <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/malleoli/approach/posteromedial-approach>
- **[r51]** AO Foundation. Anteromedial or anterolateral approach to the distal tibia. En: AO Surgery Reference [Internet]. Davos: AO Foundation; [consultado 2026 oct 10]. Disponible en: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anteromedial-or-anterolateral-approach <https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/approach/anteromedial-or-anterolateral-approach>
- **[r56]** Zhong S, Shen L, Zhao JG, Chen J, Xie JF, Shi Q, et al. Comparison of Posteromedial Versus Posterolateral Approach for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. Orthop Surg. 2017;9(1):69-76. doi:10.1111/os.12308. <https://doi.org/10.1111/os.12308>
- **[r57]** Khandge A, Salunkhe R, Kale A, Medapati S, Sharma P, Kulkarni K, et al. Posterolateral Versus Posteromedial Approach for Posterior Malleolus Fixation in Trimalleolar Fractures of the Ankle. Cureus. 2024;16(9):e69402. doi:10.7759/cureus.69402. <https://doi.org/10.7759/cureus.69402>
- **[r68]** Behery OA, Narayanan R, Konda SR, Tejwani NC, Egol KA. Posterior Malleolar Fixation Reduces the Incidence of Trans-Syndesmotic Fixation in Rotational Ankle Fracture Repair. Iowa Orthop J. 2021;41(1):121-125. <https://pubmed.ncbi.nlm.nih.gov/34552413/>