Semiextended positioning can improve the surgeon's ability to obtain, maintain, and fluoroscopically evaluate a fracture reduction when performing fixation with an intramedullary nail, especially in fractures at the proximal and distal ends. Furthermore, this position allows for evaluation of instrument placement, including the start point, without moving the fluoroscopic unit into extremes of angulation or compromising the quality of the beam orientation. The intraarticular suprapatellar approach has been described as a soft tissue approach to maintain the leg in a position that would not complicate management of these fractures, especially those in the proximal third of the tibia. A semiextended extraarticular soft tissue approach to the start point was described by Kubiak et al, and the lateral parapatellar version has become commonly used on the Orthopaedic Trauma Service at Washington University in Saint Louis. This video demonstrates advantages of semiextended positioning while performing reduction and intramedullary nail fixation for distal tibia fractures. This lateral parapatellar approach can be performed without specialized instrumentation, results in precise establishment of the start point and completion of the fixation without injury to the knee.