Patients are counseled that, although fibula fractures. We'll assume you're ok with this, but you can opt-out if you wish. 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 . The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Treatment may be nonoperative or operative depending on patient age, fracture displacement, and fracture morphology. Damage to this nerve may result in deficits in those movements. Tibia and fibula fractures in soccer players. Position. High-energy fractures, such as those caused by serious car accidents or major falls, are more common in older children. Diagnosis is made with plain radiographs of the ankle. It is caused by a pronation-external rotation mechanism. Surgery may also be needed depending on the wound size, amount of tissue damage and any vascular (circulation) problems. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Incision. The fibula is one of the two long bones in the leg, and, in contrast to the tibia, is a non-weight bearing bone in terms of the shaft. Diagnosis is made with plain radiographs of the ankle. Etiology. Pediatric Distal Tibial Fracture. Epidemiology of fractures in England and Wales. Orthobullets Team Trauma - Ankle Fractures; Listen Now 38:12 min. "use strict";var wprRemoveCPCSS=function wprRemoveCPCSS(){var elem;document.querySelector('link[data-rocket-async="style"][rel="preload"]')?setTimeout(wprRemoveCPCSS,200):(elem=document.getElementById("rocket-critical-css"))&&"remove"in elem&&elem.remove()};window.addEventListener?window.addEventListener("load",wprRemoveCPCSS):window.attachEvent&&window.attachEvent("onload",wprRemoveCPCSS); BONE DYSPLASIAS, METABOLIC BONE DISEASES, AND GENERALIZED SYNDROMES, THE ORTHOPAEDIC MANAGEMENT OF MYELODYSPLASIA AND SPINA BIFIDA, The Diagnosis and Management of Musculoskeletal Trauma, Surgical Reconstruction of the Lateral Collateral Ligament, Staying Out of Trouble with the Hip: Please . Accept 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. (0/3). The deep peroneal nerve is responsible for sensation over the first dorsal webspace. These fractures are usually transverse (across) or oblique (slanted) breaks in the bone. It is the main weight-bearing bone of the two. This article focuses on the shaft of the fibula, which can be located between the neck of the fibula, the narrowed portion just distal to the fibular head, and the lateral malleolus, which in concert with the posterior and medial malleoli, form the ankle joint. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. A common result of damage to the deep peroneal nerve is drop foot, in which there is a loss of the capacity to dorsiflex the foot. Treatment is generally operative with intramedullary nailing. The tibia is much thicker than the fibula. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. This type of fracture usually results from high-energy trauma or penetrating wounds. The proximal fibula is the insertion point for the biceps femoris posterolaterally, the soleus posteriorly, and the peroneus longus and extensor digitorum longus anteiorly. Figure 3 Normal syndesmotic relationships include a tibiofibular clear space (open arrows) <6 . Sometimes they may also involve the fracture of the growth plate (physis) located at each end of the tibia. 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). Repair of the deltoid ligament tear is not believed to be necessary (. van Staa TP, Dennison EM, Leufkens HGM, et al. Treatment may be nonoperative or operative depending on . (1/3), Level 3 Distal tibial physeal fractures in children that may require open reduction. Are you sure you want to trigger topic in your Anconeus AI algorithm? The RICE protocol, with elastic wrap compression and pain medication, may be sufficient. - Radiographic Studies. - C1 diaphyseal fracture of the fibula, simple. Obtain AP and lateral views of the knee to look for associated injury to the knee. Obtain AP and lateral views of the shafts of the tibia and fibula. Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. The fibula and tibia connect via an interosseous membrane, which attaches to a ridge on the medial surface of the fibula. Q: Do syndesmotic screws require removal? Then the injury is cleaned to remove any debris and bone fragments. Are you sure you want to trigger topic in your Anconeus AI algorithm? Although tibia and fibula shaft fractures are amongst the most common long bone fractures, there is little literature citing the incidence of isolated fibula shaft fractures. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Question SessionAnkle Fractures & Replantation. Patients require pain medicine as appropriate. Anterior tibiofibular ligament disruption, 3. The fibula is one of the two long bones in the leg, and, in contrast to the tibia, is a non-weight bearing bone in terms of the shaft. The superficial peroneal nerve also gives sensation to the dorsum of the foot. isolated but, in general, the force required to fracture the fibula. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this contrasts with the treatment of lateral malleolus fractures, which, although it is part of the fibula, technically, are categorized as ankle fractures and, therefore, have different treatment principles. Medial malleolus transverse fracture or disruption of deltoid ligament, A - infrasyndesmotic (generally not associated with ankle instability), avulsion fracture of posterior tibia resulting from tripping, AITFL avulsion off anterior fibular tubercle usually Fractures of the tibia and fibula are typically diagnosed through physical examination andX-rays of the lower extremities. (0/3), Level 5 Weber C fractures can be further subclassified as 6. This type of injury is known as a stress fracture. Tornetta P, III, Spoo JE, Reynolds FA, et al. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Symptoms of a fibula stress fracture. A physical examination and X-rays are used to diagnose tibia and fibula fractures. The treatment depends on the severity of the injury and age of the child. The following article will focus on fractures of the fibula that are proximal to the ankle joint and the treatment of such fractures. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Talofibular sprain or distal fibular avulsion, 1. One of the common types in children is the distal tibial metaphyseal fracture. The superficial peroneal nerve innervates the musculature of the lateral compartment and is responsible for eversion and, to a much milder degree, plantarflexion of the foot. Make linear longitudinal incision along the posterior border of the fibula (length depends on desired exposure) may extend proximally to a point 5cm proximal to the fibular head. - comminuted fractures of the fibula are often high energy injures resulting from direct lateral trauma or vertical loading; - comminution alters landmarks & complicates rotation and length assessment; It's possible to fracture the fibula by placing too much pressure on it over and over again. There are three types of tibial shaft fractures: These fractures occur at the ankle end of the tibia. - C3 proximal fracture of the fibula. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture. Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint. 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. Copyright 2023 Lineage Medical, Inc. All rights reserved. For distal tibial fractures, fixation of the fibula: May aid in realignment or length restoration of the tibial fracture, Increases the stability of the tibial fracture repair (, Is performed with a 3.5-mm compression plate. Transverse comminuted fracture of the fibula above the level of the syndesmosis, 2. The interosseus membrane is the stout connection between the tibia . A retrospective study of two hundred . The fibula fracture may have several different patterns: The shaft of the fibula tends to heal well on its own because it is encompassed completely by vascularized muscle. Long-distance runners and hikers are at risk for stress fractures. 2023 Lineage Medical, Inc. All rights reserved. There are several ways to classify tibia and fibula fractures. Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the . 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. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. 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 becomes the lateral malleolus at the level of the ankle. Tibia and fibula fractures are characterized as either low-energy or high-energy. For prognostic reasons, severely comminuted, contaminated barnyard injuries, close-range shotgun/high-velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been included in the grade III group. 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. C3: proximal fracture of the fibula. Full healing usually is accomplished by 68 weeks. Below are some of the most common tibia and fibula fractures that occur in children. Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (. Isolated fibular fractures comprise the majority of ankle fractures in older women, occurring in approximately 1 to 2 of every 1000 White women each year [ 1 ]. Lauge Hansen classification: - classification: - C: fibula fracture above syndesmosis. The diagnosis is made by x-raying the ankle. Open reduction and internal fixation is the surgery that can be used to reposition and physically connect the bones in an open fracture. Although tibia and fibula shaft fractures are amongst the most common long bone fractures, there is little literature citing the incidence of isolated fibula shaft fractures. check firmness of each compartment to evaluate for compartment syndrome, dorsalis pedis and posterior tibial pulses - compare to contralateral side, CT angiography indicated if pulses not dopplerable, full-length AP and lateral views of the affected tibia, AP, lateral and oblique views of ipsilateral knee and ankle, repeat radiographs recommended after splinting or fracture manipulation, intra-articular fracture extension or suspicion of plateau/plafond involvement, used to exclude posterior malleolar fracture, high variation in reported incidence of posterior malleolus fracture with distal 1/3 spiral tibia fractures (25-60%), closed, low energy fractures with acceptable alignment, < 10 degrees anterior/posterior angulation, certain patients who may be non-ambulatory (ie. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. (0/3), Level 2 There are different types of fractures, which can also affect treatment and recovery. performed with the hip flexed 45, knee flexed 80, and foot is ER 15. Vertical medial malleolus and impaction of anteromedial distal tibia, 2. C2: diaphyseal fracture of the fibula, complex. Additionally, lateral collateral ligament of the knee originates from the lateral epicondlye of the femur to insert on the superior portion of the fibular head and is the . The fibula is a slender bone that lies posterolaterally to the tibia. 5.0 (1) Login. However, there is a risk of full or partial early closure of the growth plate. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. Rarely, a fracture of the fibula may be. This procedure involves placing a piece of foam in the wound and using a device to apply negative pressure to draw the edges of a wound together. If a medial malleolar fracture is present, it should be repaired with open fixation. Follow-up/referral. Physical examination shows point tenderness and swelling in the area of fracture. A CT scan may be required to further characterize the fracture pattern and for surgical planning. 12/11/2019. if skin cannot be closed, vac-assisted closure should be considered in short-term. Significant periosteal stripping and soft tissue injury, Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury. Correlation of interosseous membrane tears to the level of the fibular fracture. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals. In 1 recent study, shin guards did not seem to prevent tibia and fibula fractures in soccer players (14). Legg-Calv-Perthes, Slipped Capital Femoral Epiphysis, and Transient , Thoracic Spondylosis, Stenosis, and DISC Herniations, Musculoskeletal Tissues and the Musculoskeletal System, This website uses cookies to improve your experience. Diagnosis is made with plain radiographs of the ankle.
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