Introduction Indications: ORIF of pilon fractures open bone biopsy access to the anterior ankle joint for debridement Plane Internervous plane between Peroneus tertius (deep peroneal n.) peroneus brevis (superficial peroneal n.) Preparation Anesthesia general spinal / epidural Position place supine on table bump under ipsilateral hip Tourniquet exsanguinate leg (if using tourniquet) Approach Incision proximally centered between tibia and fibula distal extension across the ankle, centered on 4th ray Superficial dissection full thickness flaps utilized care must be taken to protect superficial peroneal nerve located in the subcutaneous tissue, immediately under the skin Deep dissection fascia incised proximally and extensor retinaculum incised over ankle anterior compartment tendons elevated and retracted medially minimal arthrotomy performed large arthrotomies lead to devascularization of the anterior distal tibia and should be avoided Proximal extension indications for proximal plate placement dissection is limited proximally by anterior compartment muscle attachments to anterior fibula Distal extension indications to access talar fractures or talonavicular injuries to allow placement of pins for distraction dissection can extend incision to talonavicular joint if needed extensor digitorum brevis must be elevated Dangers Superficial peroneal nerve Deep peroneal nerve Anterior tibial artery Clinical Images