Research Article| Volume 62, ISSUE 2, P286-290, March 2023

Anatomy of the Sural Nerve in the Posterolateral Approach to the Ankle: A Cadaveric Study

Published:August 11, 2022DOI:


      Sural nerve injury may occur during the posterolateral approach to the ankle during fracture fixation. We aimed to map its location in a posterolateral approach in cadaveric specimens. A posterolateral approach was used in 28 cadaver legs with the incision made halfway between the medial border of the fibula and the lateral border of Achilles tendon, extending proximally from the tip of the lateral malleolus. The sural nerve was identified and the distance from the distal tip of the incision to where it crossed the incision proximally was measured. The mean distance was 3.4 ± 1.2 (range 0.5-7.0) cm. In 22 cases (78.5%), the distance from the lowest part of the incision to the inferior part of the nerve was between 2.7 and 4.5 cm. The nerve did not cross the incision in 2 cases. We have demonstrated that the sural nerve crossed the posterolateral incision between 2.7 and 4.5 cm proximal to the tip of the fibula in the majority of cases. However, there remains individual anatomical variation, and we would recommend that care should be taken to look for the nerve closer to the Achilles tendon proximally and nearer the fibula distally. We hope that this information can help surgeons plan their approach and minimize iatrogenic injury to the sural nerve.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Verhage SM
        • Boot F
        • Schipper IB
        • Hoogendoorn JM.
        Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach.
        Bone Joint J. 2016; 98-B: 812-817
        • Little MT
        • Berkes MB
        • Lazaro LE
        • Sculco PK
        • Helfet DL
        • Lorich DG.
        Complications following treatment of supination external rotation ankle fractures through the posterolateral approach.
        Foot Ankle Int. 2013; 34 (Epub 2013 Feb 27): 523-529
        • Forberger J
        • Sabandal PV
        • Dietrich M
        • Gralla J
        • Lattmann T
        • Platz A.
        Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity.
        Foot Ankle Int. 2009; 30: 309-314
        • Mason LW
        • Kaye A
        • Widnall J
        • Redfern J
        • Molloy A.
        Posterior malleolar ankle fractures: an effort at improving outcomes.
        JBJS Open Access. 2019; 4 (eCollection 2019 Apr-Jun): e0058
        • Miller AN
        • Carroll EA
        • Parker RJ
        • Helfet DL
        • Lorich DG.
        Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation.
        Clin Orthop Relat Res. 2010; 468: 1129-1135
        • Mingo-Robinet J
        • López-Durán L
        • Galeote JE
        • Martinez-Cervell C.
        Ankle fractures with posterior malleolar fragment: management and results.
        J Foot Ankle Surg. 2011; 50: 141-145
        • Tenenbaum S
        • Shazar N
        • Bruck N
        • Bariteau J.
        Posterior malleolus fractures.
        Orthop Clin North Am. 2017; 48 (Epub 2016 Oct 28. Review): 81-89
        • Forberger J
        • Sabandal PV
        • Dietrich M
        • Gralla J
        • Lattmann T
        • Platz A.
        Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity.
        Foot Ankle Int. 2009; 30: 309-314
        • Lamontagne J
        • Blachut PA
        • Broekhuyse HM
        • O'Brien PJ
        • Meek RN
        Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation.
        J Orthop Trauma. 2002; 16: 498-502
        • Minihane KP
        • Lee C
        • Ahn C
        • Zhang LQ
        • Merk BR.
        Comparison of lateral locking plate and antiglide plate for fixation of distal fibular fractures in osteoporotic bone: a biomechanical study.
        J Orthop Trauma. 2006; 20: 562-566
        • Ostrum RF.
        Posterior plating of displaced Weber B fibula fractures.
        J Orthop Trauma. 1996; 10: 199-203
        • Choi JY
        • Kim JH
        • Ko HT
        • Suh JS.
        Single oblique posterolateral approach for open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture.
        J Foot Ankle Surg. 2015; 54: 559-564
        • Ellapparadja P
        • Husami Y
        • McLeod I.
        Safety profile of sural nerve in posterolateral approach to the ankle joint: MRI study.
        Eur J Orthop Surg Traumatol. 2014; 24 (Epub 2013 Oct 25): 615-619
        • Jowett AJ
        • Sheikh FT
        • Carare RO
        • Goodwin MI
        Location of the sural nerve during posterolateral approach to the ankle.
        Foot Ankle Int. 2010; 31: 880-883
        • Bai L
        • Zhang W
        • Han Y
        • Huang W
        • Zhang H.
        Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery.
        Neural Regen Res. 2015; 10: 99
        • Jeon S
        • Paik D
        • Hwang Y.
        Variations in sural nerve formation pattern and distribution on the dorsum of the foot.
        Clin Anat. 2017; 30: 525-532
        • Aktan-Ikiz ZA
        • Ucerler H
        • Bilge O
        The anatomic features of the sural nerve with an emphasis on its clinical importance.
        Foot Ankle Int. 2005; 26: 560-567
        • Solomon LB
        • Ferris L
        • Tedman R
        • Henneberg M
        Surgical anatomy of the sural and superficial fibular nerves with an emphasis on the approach to the lateral malleolus.
        J Anat. 2001; 199: 717-723
        • Webb J
        • Moorjani N
        • Radford M
        Anatomy of the sural nerve and its relation to the Achilles tendon.
        Foot Ankle Int. 2000; 21: 475-477
        • Duparc J
        European Federation of National Associations of Orthopedics and Traumatology. Surgical Techniques in Orthopedics and Traumatology.
        Elsevier, Paris; Oxford2002
        • Porter KJ
        • Robati S
        • Karia P
        • Portet M
        • Szarko M
        • Amin A.
        An anatomical and cadaveric study examining the risk of sural nerve injury in percutaneous Achilles tendon repair using the Achillon device.
        Foot Ankle Surg. 2014; 20 (Epub 2013 Dec 6. PubMed PMID: 24796825): 90-93
        • Li S.
        Wound and sural nerve complications of the Sinus Tarsi approach for calcaneus fractures.
        Foot Ankle Int. 2018; 39 (Epub 2018 May 16. PubMed PMID: 29766742): 1106-1112
        • Williams Pl
        • Warwick R
        • Dyson M
        • Bannister Lh
        Gray's Anatomy.
        37th edn. Churchill Livingstone, Edinburgh1989
        • Lawrence S
        • Botte M
        The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications.
        Foot Ankle Int. 1994; 15: 490-494
        • Mizia E
        • Pękala P
        • Chomicki-Bindas P
        • Marchewka W
        • Loukas M
        • Zayachkowski AG
        • Tomaszewski K.
        Risk of injury to the sural nerve during posterolateral approach to the distal tibia: an ultrasound simulation study.
        Clin Anatomy. 2018; 31: 870-877