Correlation of interosseous membrane tears to the level of the fibular fracture. Fibula Stress Fracture - Symptoms, Causes, Treatment & Rehabilitation 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. leads to spiral fracture pattern with fibula fracture at a different level. The tibia is much thicker than the fibula. after fixing posterior malleolus move back to fibula fracture; place lag screw (2.7mm screw/2.0mm drill) followed with 1/3 tubular plate using antiglide technique on . Mechanism of Injury [edit | edit source]. The tibia is much thicker than the fibula. bypass fracture, likely adjacent joint (i.e. Below are some of the most common tibia and fibula fractures that occur in children. Both the posterior and medial malleolus arepart of the distal end of the tibia. Follow-up/referral. paralyzed), or those unfit for surgery, angulation and rotational alignment are well maintained with casting, however, shortening is hard to control, risk of shortening higher with oblique and comminuted fracture patterns, risk of varus malunion with midshaft tibia fractures and an intact fibula, high success rate if acceptable alignment maintained, non-union occurs in approximately 1% of patients treated with closed reduction, all open tibia fractures require an emergent I&D, surgical debridement within 12-24 hours of injury, wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting, all open tibia fractures require immediate antibiotics, should be administered within 3 hours of injury, standard abx for open fractures (institution dependent), cephalosporin given continuously for 24 hours, after definitive surgery in Grade I, II, and IIIA open fractures, aminoglycoside added in Grade IIIB injuries, tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary, early antibiotic administration is the most important factor in reducing infection, emergent and thorough surgical debridement is also an, must remove all devitalized tissue including cortical bone, open fractures with soft tissue defects/contamination, uniplanar, circular, hybrid external fixators all available, should be converted to intramedullary nail within 7-21 days, ideally less than 7 days, longer time to union and worse functional outcomes, high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis, unacceptable alignment with closed reduction and casting, soft tissue injury that will not tolerate casting, ipsilateral limb injury (i.e., floating knee), reamed nailing allows for larger diameter nail, provisional reduction techniques (blocking screws, plating, etc), particularly useful for proximal 1/3 tibial shaft fractures, for closed tibia fractures treated with nailing, risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern, shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting, decreased malalignment compared to external fixation, improved fracture alignment with suprapatellar nailing, reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial), reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures, recent studies show no adverse effects of reaming (infection, embolism, nonunion), reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise, higher rate of locking screw breakage with unreamed nailing, proximal tibia fractures with inadequate proximal fixation from IM nailing, distal tibia fractures with inadequate distal fixation from IM nail, tibia fractures in the setting of adjacent implant/hardware (i.e. Read More, Copyright 2007 Lippincott Williams & Wilkins. If a fibula fracture is associated with a. Sproule JA, Khalid M, OSullivan M, et al. Are you sure you want to trigger topic in your Anconeus AI algorithm? Maisonneuve fracture | Radiology Reference Article | Radiopaedia.org A physical examination and X-rays are used to diagnose tibia and fibula fractures. Weber C fractures can be further subclassified as 6. Etiology. 2023 Lineage Medical, Inc. All rights reserved. - frx above the syndesmotic result from external rotation or abduction forces that also disrupt. a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint. Weightbearing on the involved leg may be allowed as tolerated by the patient. highest incidence in male is between 15-24 years of age, highest incidence in females is 75-84 years of age, modified hinge joint consisting of tibia, fibula, and talus, tibial plafond and talus are broader anteriorly and wider laterally, extends from medial malleolus to broad insertion onto navicular, sutentaculum tali, and talus, primary restraint to anterior displacement, IR, and inversion of talus, strongest ligament of lateral complex and least likely to be disrupted, anterior inferior tibiofibular ligament (AITFL), originates from anterolateral tubercle of distal tibia (Chaput), inserts anteriorly onto lateral malleolus (Wagstaffe), posterior inferior tibiofibular ligament (PITFL), broad origin from posterior tibia (Volkmann's fragment), inserts onto posterior aspect of lateral malleolus, distal continuation of intraosseous membrane, peroneus longus and brevis pass along posterior groove of lateral malleolus, at risk with posterolateral fibular plating, located posterior and inferior at the level of the medial malleolus, at risk with posterior placement of medial malleolus screws, course over anterior ankle between EDL and EHL, course posterior to medial malleolus between FDL and FHL, crosses anteriorly over fibula about distal 1/3, at risk with posterolateral and direct lateral approach to fibula proximally and with anterior/anterolateral approaches, at risk with posterolateral and direct lateral approach to fibula, primary restraint to anterolateral talar displacement, acts as buttress to prevent lateral displacement of talus, dorsiflexion results in fibula ER and lateral translation, accommodating anteriorly wider talus, plantarflexion results in narrower, posterior aspect of the talus leading to IR of talus, based on combination of foot position and direction of force applied at the time of injury, has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures, 1. However, there is a risk of full or partial early closure of the growth plate. The injury is common in athlete who is engaged in collision or contact sport . There will be a pain in the lower leg on weight-bearing although . Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the . Outcome after surgery for Maisonneuve fracture of the fibula. prior total knee arthroplasty). They account for 10 to 15 percent of all pediatric fractures. Open reduction and internal fixation is the surgery that can be used to reposition and physically connect the bones in an open fracture. compared to IM nailing of tibia fractures: increased risk of wound complications and hardware irritation, similar rates of union in closed fractures, greater radiation exposure intraoperatively, risk of damage to the superficial peroneal nerve during percutaneous screw insertion, holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk, prior studies have demonstrated some use in, outcomes (controversial, as recent studies have not fully supported these findings), decrease need for subsequent autologous bone-grafting, decrease need for secondary invasive procedures, no current scoring system to determine if an amputation should be performed, relative indications for amputation include, most important predictor of eventual amputation is the severity of ipsilateral extremity, most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center, study shows no significant difference in functional outcomes between amputation and salvage, loss of plantar sensation is not an absolute indication for amputation, functional (patellar tendon bearing) brace at around 4 weeks, close follow-up with repeat radiographs to ensure no displacement, can wedge cast to correct slight deformity, within 24 hours of initial injury to decrease risk of infection, sharp debridement of nonviable soft tissue & bone, thorough irrigation of contaminated wound, immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension. Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (. 5.0 (1) Login. Fractures of the fibula often involve a syndesmotic injury (called Maisonneuve fractures). Posterolateral corner (PLC) injuries are traumatic knee injuries that are associated with lateral knee instability and usually present with a concomitant cruciate ligament injury (PCL > ACL). There are different types of fractures, which can also affect treatment and recovery. Vaccines & Boosters | Testing | Visitor Guidelines | Coronavirus. Distal tibial physeal fractures in children that may require open reduction. proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures. Wang Q, Whittle M, Cunningham J, et al. This type of fracture usually results from high-energy trauma or penetrating wounds. 12/11/2019. Figure 3 Normal syndesmotic relationships include a tibiofibular clear space (open arrows) <6 . Fractures of the fibular shaft occurring without ankle injury nearly always are associated with tibial shaft fractures. Ankle Fractures - Pediatric - Pediatrics - Orthobullets The shaft of the fibula serves as origin for the peroneus longus, peroneus brevis, peroneus tertius, extensor digitorum longus, extensor hallucis longus, tibialis posterior, soleus and flexor hallucis longus. There are several distinct portions of the fibula in terms of structure, including the head, neck, shaft, and the distal end termed the lateral malleolus. It is caused by a pronation-external rotation mechanism. Ulnar side of hand. accounts for 25-40% of all physeal injuries (second most common), accounts for 5% of all pediatric fractures, pediatric ankle fractures are a common injury that includes, twisting injury, i.e. Repair of the deltoid ligament tear is not believed to be necessary (. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. C3: proximal fracture of the fibula. Fibula Fractures - PubMed The fracture occurs from a direct blow to the outside of the leg, from twisting the lower leg awkwardly and, most common, from a severe ankle sprain. At its most proximal part, it is at the knee just posterior to the proximal tibia, running distally on the lateral side of the leg where it . A lateral malleolus fracture is a fracture of the lower end of the fibula. counterpart of LeFortWagstaffe fracture), medial sided swelling, tenderness, and ecchymosis not sensitive for medial stability, palpate proximal fibula for Maisonneuve fracture, most appropriate stress radiograph to assess competency of deltoid ligament, foot dorsiflexed and ER with tibia stabilized, more sensitive to injury than medial tenderness, ecchymosis, or edema, gravity stress radiograph is equivalent to manual stress radiograph, difficult for patients to tolerate in acute setting, it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements, normal <6 mm on both AP and mortise views, bisection of line through tibial anatomical axis and line through tip of both malleoli, shortening of lateral malleoli fractures can lead to increased talocrural angle, talocrural angle is not 100% reliable for estimating restoration of fibular length, can also utilize realignment of the medial fibular prominence with the tibiotalar joint, 25% of surgeons would change operative technique after CT, assess for anteromedial impaction of tibial plafond and talar articular cartilage injury, axial and sagittal views most useful to assess posterior malleolus, size and shape of posterior malleolus fragment, evaluate for soft tissue or cartilaginous injuries, positive anterior drawer or talar tilt test, increased medial clear space or tibiofibular diastasis on stress view, inability or weakness with plantar flexion, increased resting dorsiflexion when prone with knees bent, Chaput fragment, Volkmann fragment, medial malleolus, central impaction, high energy with extensive soft tissue injury, 25% open, x-ray shows dislocation of talus from calcaneous or navicular bone, avulsion tip fractures of medial or lateral malleolus, bimalleolar or bimalleolar-equivalent fracture, posterior malleolar fracture with > 25% or > 2mm step-off, goal of treatment is stable anatomic reduction with restoration of mortise, see fracture patterns below for specific treatment, direct reduction of medial and lateral malleolus fractures, indirect reduction of posterior malleolus, facilitates direct reduction of posterior malleolus, common approach for fibula ORIF syndesmotic fixation, concomitant access to posterior fibula and posterior malleolus, access to medial malleolus and posterior malleolus, common approach for medial malleolus ORIF, prolonged recovery expected (2 years to obtain final functional result), anatomic reduction is considered most important factor for satisfactory outcome, ORIF superior to closed treatment of bimalleolar fractures, improved incisional perfusion with Allgwer-Donati sutures, proper braking response time (driving) returns to baseline at 9 weeks after surgery, braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of lower extremity, severe open fractures with gross contamination, poor soft tissue requiring close monitoring, lower risk of redislocation and skin complication in ankle fracture dislocation vs splint, isolated medial malleolus fracture without talar shift, deep deltoid inserts on posterior colliculus, good outcomes with >95% union rate for isolated injury, lag screw fixation stronger if placed perpendicular to fracture line, bicortical 3.5 mm fully-threaded screw (lag by technique) superior to unicortical 4.0 mm partially-threaded screw (lag by design), > 4-5 mm of medial clear space widening on stress views considered unstable, recent studies show deep deltoid intact with 8-10 mm of widening on stress view, open reduction and internal fixation (ORIF), presence of talar shift on static or stress view (bimalleolar equivalent), one-third tubular or anatomic distal fibular plate, stiffest fixation construct for the fibula is a locking plate, posterior antiglide plating is biomechanically superior to lateral plate, disadvantage of peroneal tendon irritation if plate too distal, newer implants have improved axial and rotational control with distal/proximal fixation, useful for poor soft-tissue envelopes or high risk for wound-healing complication, similar outcomes with operative and non-operative treatment if stable mortise, Bimalleolar-Equivalent Fracture (deltoid ligament tear with fibular fracture), low demand and unable to tolerate surgery, lateral malleolus fracture with talar shift (static or stress view), assess syndesmotic stability after fixation of lateral malleolus, not necessary to repair medial deltoid ligament, explore medially if unable to reduce mortise and deltoid ligament potentially interposed, lower rate of nonunion and fracture displacement with operative treatment, Bimalleolar (MEDIAL AND LATERAL) Fracture, low demand and unable to undergo surgical intervention, any displacement or talar shift (static or stress view), size should be calculated on CT since plain radiographs are unreliable, interval between FHL and peroneal tendons, common approach since posterior malleolus fractures are frequently posterolateral, decision of approach will depend on location of fracture, degree of displacement, and need for fibular fixation, stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus vs 40% with isolated, PITFL may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation, stress examination of syndesmosis still required after posterior malleolar fixation, 40-90% of distal third spiral tibia fractures have an associated posterior malleolus fracture, rare fracture-dislocation of ankle where fibula is entrapped behind tibia and is irreducible, posterolateral ridge of the distal tibia hinders reduction of the fibula, open reduction of fibula and internal fixation is required, fracture-dislocation of the ankle due to hyperplantarflexion, main feature is a vertical shear fracture of the posteromedial tibial rim, double cortical density at the inferomedial tibial metaphysis, ORIF of posterior malleolus with antiglide plating, primary closure at index procedure can be performed in appropriately-selected grade I, II, and IIIA open fractures in otherwise healthy patients without gross contamination, higher incidence with higher fibula fractures, fixation usually not required when fibula fracture within 4.5 cm of plafond, measure tibiofibular clear space 1 cm above joint, abduction/external rotation stress of dorsiflexed foot, lateral stress radiograph has greater interobserver reliability than an AP/mortise stress film, instability of the syndesmosis is greatest in the anterior-posterior direction, patient placed in lateral decubitus position, similar effectiveness to manual ER stress test, bone hook around fibula used to pull while placing counter traction on tibia, tibiofibular clear space (AP) greater than 5 mm, length and rotation of fibula must be accurately restored, "Dime sign"/Shentons line to determine length of fibula, fixing lateral and/or posterior malleolus first my obviate need for syndesmotic fixation, outcomes are strongly correlated with anatomic reduction, maximum dorsiflexion not required during screw placement (over-tightening), open reduction required if closed reduction unsuccessful or questionable, one or two cortical screw(s) or suture-button devices 2-4 cm above joint, angled posterior to anterior 20-30 degrees (fibula posterior to tibia), suture button has lower rate of malreduction and reoperation rate than screws, no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year, outcome may be worse with maintenance of intact screws, screws should be maintained in place for at least 8-12 weeks, must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation, any postoperative malalignement or widening should be treated with open debridement, reduction, and fixation, Diabetic Ankle Fractures (with or without Neuropathy), poor circulation impairs wound and fracture healing, multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury), tibiotalar Steinmann pins or hindfoot nailing, augment with intramedullary fibula K-wires, stiffer, more rigid fibular plates (instead of 1/3 tubular plates), maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients), largest risk factor for diabetic patients is presence of, articular impaction of tibial plafond in SAD injuries should be addressed at time of surgery, corrective osteotomy requires obtaining anatomic fibular length and mortise correction for optimal outcomes, Loss of dorsiflexion with posterior fixation, rare with anatomic reduction and fixation, very common in "log-splitter" type injuries (trans-syndesmotic fracture-dislocations in which the talus is driven into the distal tibiofibular articulation), superficial peroneal nerve injury (10-15%), At risk with lateral approach to distal fibula, posterolateral, and anterior/anterolateral approaches, Two terminal nerve branches that innervate dorsum of the foot, protruding screw head in most distal hole of fibula plate, at risk with posterior medial malleolus screw placement, Excellent for stable ankle fractures treated nonoperatively, Outcomes following operative treatment generally very favorable, 90% mild/no ankle pain with minimal limitations and near full functional recovery at 1 yr, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries.