Obtain 3 views of the ankle (AP, lateral, and mortise) to look for ankle fracture or syndesmotic disruption. There is very limited mobility between this syndesmosis. It is the main weight-bearing bone of the two. C3: proximal fracture of the fibula. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. Transverse comminuted fracture of the fibula above the level of the syndesmosis, 2. The superficial peroneal nerve also gives sensation to the dorsum of the foot. The injury is common in athlete who is engaged in collision or contact sport . Epiphyseal fractures of the distal ends of the tibia and fibula. Located posterolaterally to the tibia, it is much smaller and thinner. - C3 proximal fracture of the fibula. 2023 Lineage Medical, Inc. All rights reserved, Ohio Health Orthopedic Trauma and Reconstructive Surgery, 2. 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 . One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. New masking guidelines are in effect starting April 24. Fibular fractures in adults are typically due to trauma. Common proximal tibial fractures include: This type of fracture takes place in the middle, or shaft (diaphysis), of the tibia. Symptoms of a fibula stress fracture. Fibula bone fracture is a common injury seen in the emergency room. 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. Diagnosis is made with plain radiographs of the ankle. Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories: low-energy injuries such as ground level falls and athletic injuries; high-energy injuries such as motor vehicle injuries, pedestrians struck by motor vehicles, and gunshot wounds. 12/11/2019. This type of fracture usually results from high-energy trauma or penetrating wounds. Please Login to add comment. Pronation - External Rotation (PER) 1. Fractures of the fibular shaft occurring without ankle injury nearly always are associated with tibial shaft fractures. Open fractures of the tibia are common among children and adults. Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals. Anterior tibiofibular ligament disruption, 3. a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint. The deep peroneal nerve innervates the musculature of the anterior compartment and is responsible for the dorsiflexion of the foot and toes. Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the . 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 . 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. Etiology. The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Please . Low-energy, nondisplaced (aligned) fractures, sometimes called toddlers fractures, occur from minor falls and twisting injuries. Nonsurgical Treatment. - C2 diaphyseal fracture of the fibula, complex. Then the injury is cleaned to remove any debris and bone fragments. open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture), construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct, incision from inferior pole of patella to just above tibial tubercle, identify medial edge of patellar tendon, incise, insert guidewire as detailed below and ream, can lead to valgus malalignment in proximal 1/3 tibial fractures, helps maintain reduction when nailing proximal 1/3 fractures, can damage patellar tendon or lead to patella baja (minimal data to support this), semiextended medial or lateral parapatellar, used for proximal and distal tibial fractures, skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon, knee should be in 5-30 degrees of flexion, choice to go medial or lateral is based of mobility of patella in either direction, identify starting point and ream as detailed below, suprapatellar nailing (transquadriceps tendon), easier positioning if additional instrumentation needed, more advantageous for proximal or distal 1/3 tibia fractures, starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view, in proximal 1/3 tibia fractures starting point should cheat laterally to avoid classic valgus/procurvatum deformity, ensure guidewire is aligned with tibia in coronal and sagittal planes as you insert, opening reamer is placed over guidewire and ball-tipped guidewire can then be passed, spanning external fixation (ie. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 2023 - TeachMe Orthopedics. The fibular shaft is an origin for multiple muscles of the leg, including musclesof the anterior compartment (extensor digitorum longus, extensor hallucis longus, peroneus tertius), the lateral compartment (peroneus longus, peroneus brevis), the superficial posterior compartment (soleus), and the deep posterior compartment (tibialis posterior and flexor hallucis longus). Patients are followed at 1-month intervals with plain radiographs until the fractures are healed. bypass fracture, likely adjacent joint (i.e. Tornetta P, III, Spoo JE, Reynolds FA, et al. The interosseus membrane is the stout connection between the tibia . Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: Preparation. Fibula and its ligaments in load transmission and ankle joint stability. (0/3). Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. Both the posterior and medial malleolus arepart of the distal end of the tibia. A splint or cast may be applied to increase comfort but is not essential. Fibular fractures may also occur as the result of repetitive loading and in this case they are referred to as stress fractures. Overtightening of the ankle syndesmosis: is it really possible? Are you sure you want to trigger topic in your Anconeus AI algorithm? This type of injury is known as a stress fracture. They are also called tibial plafond fractures. - Radiographic Studies. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. a combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle), knee positioned at 90 and external rotation and valgus force applied to tibia, as the knee is extended the tibia reduces with a palpable clunk, tibia reduces from a posterior subluxed position at ~20 of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee), altered sensation to dorsum of foot and weak ankle dorsiflexion, approximately 25% of patients have peroneal nerve dysfunction, may see avulsion fracture of the fibula (arcuate fracture ) or femoral condyle, side-to-side difference 2.7-4 mm = isolated LCL tear, primary varus = tibiofemoral malalignment, secondary varus = LCL deficiency with increased lateral opening, triple varus = remaining PLC deficient, overall varus recurvatum alignment, necessary to determine mechanical axis and if a, look for injury to the LCL, popliteus, and biceps tendon, coronal oblique thin-slice through the fibular head are best at visualizing the PLC structures, hinged knee brace locked in extension x4 weeks, followed by progressive functional rehabilitation, midsubstance repair have 40% failure rate following repair, repair of LCL, popliteus tendon and/or popliteofibular ligament should be performed if structures can be, anatomically reduced to their attachment site, avulsion fracture of fibular head can be treated with screws or suture anchors, avulsion injuries where repair is not possible or tissie is poor quality, goal is to reconstruct LCL and the popliteofibular ligament using a free tendon graft (semitendinosus or achilles), soft tissue graft passed through bone tunnel in fibular head, limbs are then crossed to create figure-of-eight and fixed to lateral femur to a single tunnel, trans-tibial double-bundle reconstruction, split achilles tendon is fixed to isometric point of the femoral epicondyle, one tibia-based limb and one fibula-based limb, fibula-limb is fixed to the fibular head with a bone tunnel and transosseous sutures to reconstruct the LCL, tibia-limb is brought through the posterior tibia to reconstruct the popliteofibular ligament, proximal attachment site at anatomic femoral LCL attachment, through the fibular head lateral to medial, docking into the tibial tunnel posterior to anterior with graft #2, graft #2 reconstructs the popliteus tendon, proximal attachment site at the anatomic popliteus tendon attachment, docking into the tibial tunnel posterior to anterior with graft #1, hinged knee brace, nonweightbearing for 6 weeks, range of motion protocols differ between surgeons, some advocate for passive ROM immediately 0-90, others immobilize for 2 weeks, then begin motion, at 6 weeks, begin weightbearing and closed-chain strenghtening, return to activities / sports ~ 6 to 9 months, operative treatment has improved outcomes compared to nonoperative treatment, repair has higher failure rate than reconstruction, particularly for midsubstance injuries, but also for soft tissue avulsions, anatomic reconstruction restores rotatory stability, but not all varus stability on stress testing, PLC reconstruction, +/- ACL reconstruction, +/-, acute and chronic combined ligament injuries, PLC reconstruction should be performed at same time or prior to (as staged procedure) ACL or PCL to prevent early cruciate failure, indicated in patients with varus mechanical alignment, failure to correct bony alignment jeopardizes ACL and PLC reconstruction success, ACL reconstruction + PLC repair 33% achieved IKDC grade A or B compared to 88% of patients who underwent ACL + PLC reconstruction, failure to identify a PLC injury will lead to failure of ACL or PCL reconstruction, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Proximal Tibiofibular Joint Ganglion Cysts, Pre-Participation Physical Exam in Athlete, Concussions (Mild Traumatic Brain Injury). The following article will focus on fractures of the fibula that are proximal to the ankle joint and the treatment of such fractures. Talofibular sprain or distal fibular avulsion, 1. performed with the hip flexed 45, knee flexed 80, and foot is ER 15. Proper . These fractures occur in the knee end of the tibia and are also called tibial plateau fractures. The diagnosis is made by x-raying the ankle. Are you sure you want to trigger topic in your Anconeus AI algorithm? Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. If patient is unable to participate in examination and concern is high clinically, intracompartmental compartment measurements should be performed, floating knee is an indication for antegrade tibial nailing and retrograde femoral nailing, distal 1/3 and spiral tibial shaft fractures, tibial shaft is triangular in cross-section, proximal medullary canal is centered laterally, important for start point with IM nailing, anteromedial tibial crest is composed of dense, cortical bone and rests in a subcutaneous position, making it useful as a landmark, tibial tubercle sits anterolaterally, approximately 3 cm distal to joint line, gerdy's tubercle lies laterally on proximal tibia, pes anserinus lies medially on proximal tibia, attachment of sartorius, semitendinosus, and gracilis, superficial medial collateral ligament (MCL) attaches approximately 5-7 cm distal to joint line deep to the pes anserinus, adjacent fibula supports attachments for the lateral collateral ligament complex and long head of biceps femoris, tibia is responsible for about 80-85% of lower extremity weight-bearing, fibrous structure interconnecting tibia/fibula which provides axial stability, fibula rests in distal tibial incisura and is stabilized by syndesmotic ligaments, anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), inferior transverse tibiofibular ligament (ITL), interosseous ligament (IOL) - continuation of interosseus membrane, syndesmotic stability can be affected by distal, spiral tibial shaft fractures, Fracture classification is primarily descriptive based on pattern and location, Oestern and Tscherne Classification of Closed Fracture Soft Tissue Injury, Injuries from indirect forces with negligible soft-tissue damage, Superficial contusion/abrasion, simple fractures, Deep abrasions, muscle/skin contusion, direct trauma, impending compartment syndrome, Excessive skin contusion, crushed skin or destruction of muscle, subcutaneous degloving, acute compartment syndrome, and rupture of major blood vessel or nerve, Gustilo-Anderson Classification of Open Tibia Fractures, Limited periosteal stripping, clean wound < 1 cm, Minimal periosteal stripping, wound >1 cm in length without extensive soft-tissue injury damage. 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. A physical examination and X-rays are used to diagnose tibia and fibula fractures. rotation about a planted foot and ankle, accounts for 35-40% of overall tibial growth and 15-20% of overall lower extremity growth, growth continues until 14 years in girls and 16 years in boys, closure occurs during an 18 month transitional period, pattern of closure occurs in a predictable pattern: central > anteromedial > posteromedial > lateral, closure occurs 12-24 months after closure of distal tibial physis, Ligaments (origins are distal to the physes), primary restraint to lateral displacement of talus, anterior inferior tibiofibular ligament (AITFL), extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle), plays an important role in transitional fractures (Tillaux, Triplane), posterior inferior tibiofibular ligament (PITFL), extends from posterior aspect of lateral distal tibial epiphysis (Volkmanns tubercle) to posterior aspect of distal fibula, extends from posterior distal fibula across posterior aspect of distal tibial articular surface, functions as posterior labrum of the ankle, Fracture extends through the physis and exits through the metaphysis, forming a Thurston-Holland fragment, Fracture extends through the physis and exits through the epiphysis, Seen with medial malleolus fractures and Tillaux fractures, Fracture involves the physis, metaphysis and epiphysis, Can occur with lateral malleolus fractures, usually SH I or II, Seen with medial malleolus shearing injuries and triplane fractures, Can be difficult to identify on initial presentation (diagnosis is usually made when growth arrest is seen on follow-up radiographs), Results from open injury (i.e. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. - 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; 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. However, there is a risk of full or partial early closure of the growth plate. 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. Damage to this nerve may result in deficits in those movements. Distal tibial metaphyseal fractures usually heal well after setting them without surgery and applying a cast. Orthobullets Team Trauma - Ankle Fractures; Listen Now 38:12 min. Physical examination shows point tenderness and swelling in the area of fracture. Q: Do syndesmotic screws require removal? Fractures of the proximal head and neck of the fibula are associated with substantial damage to the knee (. 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. 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. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. 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.