Indications Exposure to middle two thirds of tibia when anterior approach is not an option due to skin issues Indications include anterolateral bone grafting only provides limited exposure so of limited use for ORIF of tibia fractures Internervous Plane Interval between peroneus brevis (superficial peroneal nerve) - lateral compartment extensor digitorum longus (deep peroneal nerve) - anterior compartment Approach Position lateral decubitus or semi-lateral exsanguinate limb if desired Incision make a longitudinal incision over the anterior edge of the fibula (center it over the pathology in the tibia) Superficial dissection Incise tissue and fascia in line with the skin incision, careful not to injure the short saphenous vein that runs along the posterior border of the fibula develop plane between peroneus brevis and extensor digitorum longus dissect down to anterolateral border of the fibula protect the superficial peroneal nerve that lies on the peroneus brevis muscle Deep surgical dissection gently detach the extensor musculature form the anterior aspect of the interosseous membrane using blunt instruments or cautery follow the anterior surface of the interosseous membrane to the lateral border of the tibia (failure to stay on the surface of the interosseous membrane may lead to injury to the neurovascular bundle in the anterior compartment expose the anterolateral border of the tibia perform subperiosteal dissection (elevating tibialis anterior) of the lateral surface of tibia moving anteriorly expose desired region of the lateral surface of the tibia Dangers Short saphenous vein Superficial peroneal nerve (gives off all motor branches in upper third of leg - therefore only sensory branches at the level of this incision) injury to the nerve at this level leads to numbness on the dorsum of the foot Anterior tibial artery and deep peroneal nerve protected as long as you stay on the anterior surface of the interosseous membrane .