Introduction Provides exposure to lateral malleolus posterolateral tibia syndesmosis Indications include ORIF of fibula ORIF of syndesmosis percutaneous placement of syndesmosis screws access to the posterolateral tibia Approach Position supine with bump under buttock Incision make longitudinal incision along the posterior margin of the fibula (center incision over fracture site) extend 2 cm distal to the tip of the lateral malleolus (if needed) Superficial dissection elevate skin flaps taking care not to damage the short saphenous vein and sural nerve that runs posterior to the fibula look for the superficial peroneal nerve crossing from the lateral to anterior compartments (~10 cm proximal to tip of fibula) Deep dissection longitudinally incise the periosteum of the subcutaneous surface of the fibula strip off just enough periosteum to expose the fracture site and achieve a reduction as you extend the incision proximally take care not to damage the superficial peroneal nerve Extensile measure proximal - may be developed proximally to become continous with the Lateral approach to the fibula distal - may be extended distally to become continous with Ollier's lateral approach to the tarsus Kocher lateral approach to the ankle and tarsus Lateral approach to the calcaneus posterior can access posterolateral tibia for fixation interval is the peroneal muscles/tendons and flexor hallucis longus Dangers Sural nerve cutting may lead to formation of a painful neuroma and numbness along the lateral skin of the foot Short Saphenous vein Terminal branches of peroneal artery lie deep to medial surface of distal fibula can be damaged if dissection does not stay subperiosteal may form hematoma after removal or tourniquet Superficial peroneal nerve crosses from posterior to anterior over the fibular shaft at the proximal end of the incision