performed with the hip flexed 45, knee flexed 80, and foot is ER 15. Similar to a nondisplaced medial malleolus fracture, a nondisplaced lateral malleolus fracture can often be treated with a short leg cast or walking boot. Are you sure you want to trigger topic in your Anconeus AI algorithm? Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. All Rights Reserved. Pain will usually have developed gradually over time, rather than at a specific point in time that the athlete can recognise as when the injury occurred. - 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; 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. Maisonneuve fractures with syndesmotic injury imply injury to the medial side of the ankle joint. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Transverse comminuted fracture of the fibula above the level of the syndesmosis. The tibia is much thicker than the fibula. 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. Rarely, a fracture of the fibula may be. Mechanism of Injury [edit | edit source]. 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 . Correlation of interosseous membrane tears to the level of the fibular fracture. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. ORIF of fibula fractures; resection of fibula; excision of fibula bone lesions; Internervous plane: Between . Repair of the deltoid ligament tear is not believed to be necessary (. Are you sure you want to trigger topic in your Anconeus AI algorithm? - C3 proximal fracture of the fibula. Accept Are you sure you want to trigger topic in your Anconeus AI algorithm? 2023 - TeachMe Orthopedics. posterior border of the biceps femoris tendon, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, may be done supine with bump under affected limb or in lateral position, Make linear longitudinal incision along the, may extend proximally to a point 5cm proximal to the fibular head, begin proximally and incise the fascia taking great care not to damage the common peroneal nerve, about 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia, distal - may be extended distally to become continuous with, Kocher lateral approach to the ankle and tarsus, susceptible to injury at junction of middle and distal third of leg, if injured will cause numbness on the dorsum of the foot. Patients with fibular shaft or head fractures generally present with tenderness and swelling in the area of injury. A retrospective study of two hundred . The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. 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. Are you sure you want to trigger topic in your Anconeus AI algorithm? Long-distance runners and hikers are at risk for stress fractures. It is the main weight-bearing bone of the two. The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Common proximal tibial fractures include: This type of fracture takes place in the middle, or shaft (diaphysis), of the tibia. - frx above the syndesmotic result from external rotation or abduction forces that also disrupt. 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). Open reduction and internal fixation is the surgery that can be used to reposition and physically connect the bones in an open 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 (. Approximately 7-16% knee ligament injuries are to the posterolateral ligamentous complex, only 28% of all PLC injuries are isolated, usually combined with cruciate ligament injury (PCL > ACL), common cause of ACL reconstruction failure, contact and noncontact hyperextension injuries, three major static stabilizers of the lateral knee, most anterior structure inserting on the fibular head, originates at the musculotendinous junction of the popliteus, meniscofemoral and meniscotibial ligaments, inserts on the posterior aspect of the fibula posterior to LCL, popliteus works synergistically with the PCL to control, popliteus and popliteofibular ligament function maximally in knee flexion to resist external rotation, LCL is primary restraint to varus stress at 5 (55%) and 25 (69%) of knee flexion, arcuate complex includes the static stabilizers: LCL, arcuate ligament, and popliteus tendon, Patellar retinaculum, patellofemoral ligament, 0-5 mm of lateral opening on varus stress, 0-5 rotational instability on dial test, Sprain, no tensile failure of capsuloligamentous structures, 6-10 mm of lateral opening on varus stress, 6-10 rotational instability on dial test, Partial injuries with moderate ligament disruption, > 10 mm of lateral opening on varus stress, no endpoint, > 10 rotational instability on dial test, no endpoint, often have instability symptoms when knee is in full extension, difficulty with reciprocating stairs, pivoting, and cutting, varus thrust or hyperextension thrust with ambulation, varus laxity at 0 indicates both LCL and cruciate (ACL or PCL) injury, positive when lower leg falls into external rotation and recurvatum when leg suspended by toes in supine patient, more consistent with combined ACL and PLC injuries. Tibia and fibula fractures can be treated with standard bone fracture treatment procedures. proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures. Copyright 2023 Lineage Medical, Inc. All rights reserved. These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement. The proximal fibula is the insertion point for the biceps femoris posterolaterally, the soleus posteriorly, and the peroneus longus and extensor digitorum longus anteiorly. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint, 4. There are several ways to classify tibia and fibula fractures. Sometimes they may also involve the fracture of the growth plate (physis) located at each end of the tibia. Diagnosis is made with plain radiographs of the ankle. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. 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. (0/3), Level 1 B1 Isolated. 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. The following article will focus on fractures of the fibula that are proximal to the ankle joint and the treatment of such fractures. This may lead to a growth arrest in the form of leg length discrepancy or other deformity. Usually, it gets worse with activity and better with rest. mechanism of injury. 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. Are you sure you want to trigger topic in your Anconeus AI algorithm? These types include: lateral malleolus . isolated but, in general, the force required to fracture the fibula. Tornetta P, III, Spoo JE, Reynolds FA, et al. - C2 diaphyseal fracture of the fibula, complex. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: Preparation. Symptoms consist of pain in the calf area with local tenderness at a point on the fibula. Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals. Stress Fractures of the Fibula . Ulnar side of hand. Weightbearing on the involved leg may be allowed as tolerated by the patient. 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. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus, 4. However, there is a risk of full or partial early closure of the growth plate. Damage to this nerve may result in deficits in those movements. It's possible to fracture the fibula by placing too much pressure on it over and over again. 2023 Lineage Medical, Inc. All rights reserved, Ohio Health Orthopedic Trauma and Reconstructive Surgery, 2. It is caused by a pronation-external rotation mechanism. Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. ; Patients may report a history of direct (motor vehicle crash or axial loading) or indirect . Sproule JA, Khalid M, OSullivan M, et al. The injury is common in athlete who is engaged in collision or contact sport . The tibia is much thicker than the fibula. Tibia and fibula fractures are characterized as either low-energy or high-energy. Physical examination shows point tenderness and swelling in the area of fracture. 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. A physical examination and X-rays are used to diagnose tibia and fibula fractures. Numbness or paresthesias may arise if damage to the peroneal nerve has occurred. It is the main weight-bearing bone of the two. 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. 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. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . Orthobullets Team Trauma - Ankle Fractures; Listen Now 38:12 min. There will be a pain in the lower leg on weight-bearing although . Wounds may be treated with vacuum-assisted closure. At Another Johns Hopkins Member Hospital: Tibia fractures are the most common lower extremity fractures in children. low energy (fall from standing, twisting, etc) result of indirect, torsional injury. Symptoms of a fibula stress fracture. Diagnosis is made with plain radiographs of the ankle. There are three types of tibial shaft fractures: These fractures occur at the ankle end of the tibia. "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: Weber C fractures can be further subclassified as 6. Pearls/pitfalls. 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 . 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. The RICE protocol, with elastic wrap compression and pain medication, may be sufficient. Posterolateral Corner Injury. One of the common types in children is the distal tibial metaphyseal fracture. Diagnosis is made with plain radiographs of the ankle. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. usually associated with an injury to the medial side Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. Patients are followed at 1-month intervals with plain radiographs until the fractures are healed. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. This type of injury is known as a stress fracture. Fibular fractures may also occur as the result of repetitive loading and in this case they are referred to as stress fractures. Fractures of the fibula often involve a syndesmotic injury (called Maisonneuve fractures). Vaccines & Boosters | Testing | Visitor Guidelines | Coronavirus. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. 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. This type of fracture usually results from high-energy trauma or penetrating wounds. Both the posterior and medial malleolus arepart of the distal end of the tibia. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. With an associated knee injury, patients have pain and swelling of the knee joint. Position. Transverse comminuted fracture of the fibula above the level of the syndesmosis, 2. Fractures that involve syndesmotic injury or ankle or knee fracture often require surgical treatment. B2 w/ medial lesion (malleolus or ligament) B3 w/ a medial lesion and fracture of posterolateral tibia. The deep peroneal nerve innervates the musculature of the anterior compartment and is responsible for the dorsiflexion of the foot and toes. Distal tibial metaphyseal fractures usually heal well after setting them without surgery and applying a cast. If a medial malleolar fracture is present, it should be repaired with open fixation. Vertical medial malleolus and impaction of anteromedial distal tibia, 2. Surgery may also be needed depending on the wound size, amount of tissue damage and any vascular (circulation) problems. The fibula is a site of five muscles attachment. Fibula and its ligaments in load transmission and ankle joint stability. There are different types of fractures, which can also affect treatment and recovery. 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. The superficial peroneal nerve also gives sensation to the dorsum of the foot. They are also called tibial plafond fractures. (1/3), Level 3 A lateral malleolus fracture is a fracture of the lower end of the fibula. - Radiographic Studies. Fractures of the fibular shaft occurring without ankle injury nearly always are associated with tibial shaft fractures. Are you sure you want to trigger topic in your Anconeus AI algorithm? Incision. Fracture of the proximal fibula indicative of syndesmotic injury. A CT scan may be required to further characterize the fracture pattern and for surgical planning. Anterior tibiofibular ligament disruption, 3. bypass fracture, likely adjacent joint (i.e. Located posterolaterally to the tibia, it is much smaller and thinner. Please Login to add comment. Treatment for tibia and fibula fractures ranges from casting to surgery, depending on the type and severity of the injury. Obtain AP and lateral views of the shafts of the tibia and fibula. Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint. Medial malleolus transverse fracture or disruption of deltoid ligament, 3. These fractures occur in the knee end of the tibia and are also called tibial plateau fractures. Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. Summary. Medial malleolus transverse fracture or disruption of deltoid ligament . Read More, Copyright 2007 Lippincott Williams & Wilkins. Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (. Wang Q, Whittle M, Cunningham J, et al. Etiology. (0/3), Level 2 Patients require pain medicine as appropriate. Distal tibial physeal fractures in children that may require open reduction. The fibula is a slender bone that lies posterolaterally to the tibia. Epiphyseal fractures of the distal ends of the tibia and fibula. The fibula and tibia connect via an interosseous membrane, which attaches to a ridge on the medial surface of the fibula. Patients with tibia fractures, syndesmosis injuries, or ankle fractures should be referred to an orthopaedic surgeon. Pronation - External Rotation (PER) 1. (2/3), Level 4 Open fractures of the tibia are common among children and adults. 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Undecided In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture. Ulnar gutter splint/cast. Stromsoe K, Hoqevold HE, Skjeldal S, et al. Fractures of the tibia and fibula are typically diagnosed through physical examination andX-rays of the lower extremities. Fibula bone fracture is a common injury seen in the emergency room. - C1 diaphyseal fracture of the fibula, simple. 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. Obtain 3 views of the ankle (AP, lateral, and mortise) to look for ankle fracture or syndesmotic disruption. 2023 Lineage Medical, Inc. All rights reserved. lawnmower) or iatrogenic during surgical dissection, (patterned off adult Lauge-Hansen classification), Adduction or inversion force avulses the distal fibular epiphysis (SH I or II), Rarely occurs with failure of lateral ligaments, Further inversion leads to distal tibial fracture (usually SH III or IV, but can be SH I or II), Occasionally can cause fracture through medial malleolus below the physis, Plantarflexion force displaces the tibial epiphysis posteriorly (SH I or II), Thurston-Holland fragment is composed of the posterior tibial metaphysis and displaces posteriorly, External rotation force leads to distal tibial fracture (SH II), Thurston-Holland fragment displaces posteromedially, Easily visible on AP radiograph (fracture line extends proximally and medially), Further external rotation leads to low spiral fracture of fibula (anteroinferior to posterosuperior), External rotation force leads to distal tibial fracture (SH I or II) and transverse fibula fracture, Occasionally can be transepiphyseal medial malleolus fracture (SH II), Distal tibial fragment displaces laterally, Thurston-Holland fragment is lateral or posterolateral distal tibal metaphysis, Can be associated with diastasis of ankle joint, Leads to SH V injury of distal tibial physis, Can be difficult to identify on initial presentation (diagnosis typically made when growth arrest is seen on follow-up radiographs), distal fibula physeal tenderness may represent non-displaced SHI, full-length tibia (or proximal tibia) to rule out Maisonneuve-type fracture, assess fracture displacement (best obtained post-reduction), non-displaced (< 2mm) isolated distal fibular fracture, displaced (> 2mm) SH I or II fracture with, acceptable closed reduction (no varus, < 10 valgus, < 10 recurvatum/procurvatum, < 3mm physeal widening), or II fracture with unacceptable closed reduction (varus, > 10 valgus, > 10 recurvatum/procurvatum, > 3mm physeal widening) and > 2 years of growth remaining, displaced SH I or II fracture with unacceptable closed reduction (varus, > 10 valgus, > 10 recurvatum/procurvatum, > 3mm physeal widening) and < 2 years of growth remaining, requires adequate sedation and muscle relaxation, only attempt reduction two times to prevent further physeal injury, NWB short-leg cast if isolated distal fibula fracture, NWB long-leg cast if distal tibia fracture, interposed periosteum, tendons, or neurovascular structures, percutaneous manipulation with K wires may aid reduction, open reduction may be required if interposed tissue present, transepiphyseal fixation best if at all possible, high rate associated with articular step-off > 2mm, medial malleolus SH IV fractures have the highest rate of growth disturbance, 15% increased risk of physeal injury for every 1mm of displacement, can represent periosteum entrapped in the fracture site, partial arrests can lead to angular deformity, distal fibular arrest results in ankle valgus defomity, medial distal tibia arrest results in varus deformity, complete arrests can result in leg-length discrepancy, if < 20 degrees of angulation with < 50% physeal involvement and > 2 years of growth remaining, bar of >50% physeal involvement in a patient with at least 2 years of growth, fibular epiphysiodesis helps prevent varus deformity, if < 50% physeal involvement and > 2 years of growth remaining, contralateral epiphysiodesis if near skeletal maturity with significant expected leg-length discrepancy, typically seen in posteriorly displaced fractures, can occur after triplane fractures, SH I or II fractures, usually leads to an increased external foot rotation angle, anterior angulation or plantarflexion deformity, occurs after supination-plantarflexion SH II fractures, occurs after external rotation SH II fractures, treatment options include physical therapy, psychological counseling, drug therapy, sympathetic blockade, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease).