Fractures of the proximal head and neck of the fibula are associated with substantial damage to the knee (. 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. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . It may include some of the following approaches, used either alone or in combination: An open fracture occurs when the bone or parts of the bone break through the skin. This type of fracture usually results from high-energy trauma or penetrating wounds. performed with the hip flexed 45, knee flexed 80, and foot is ER 15. 356 plays. There are three types of tibial shaft fractures: These fractures occur at the ankle end of the tibia. Tibia and Fibula Fractures | Johns Hopkins Medicine 2023 Lineage Medical, Inc. All rights reserved. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con Weber C fractures can be further subclassified as 6. These fractures occur in the knee end of the tibia and are also called tibial plateau fractures. 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. 2023 - TeachMe Orthopedics. Proper . Pathophysiology. (0/3), Level 2
Splints and Casts: Indications and Methods | AAFP Mechanism of Injury [edit | edit source]. Fractures of the fibula often involve a syndesmotic injury (called Maisonneuve fractures). Maisonneuve fractures with syndesmotic injury imply injury to the medial side of the ankle joint. 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 . Repeated cleanings prior to closing the wound may be used instead. Summary. Fibular fractures may also occur as the result of repetitive loading and in this case they are referred to as stress fractures. muscles of the posterior compartment ( tibial nerve) Approach. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. Fracture of the proximal fibula indicative of syndesmotic injury. Outcome after surgery for Maisonneuve fracture of the fibula. Long-distance runners and hikers are at risk for stress fractures. These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement. 2023 Lineage Medical, Inc. All rights reserved, Posterior Malleolus and Fibula Fracture ORIF, Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Fracture Preparation and Reduction (Fibula), Soft Tisue Dissection (Posterior Malleolus), Fracture Preparation and Reduction (Posterior Malleolus), firmly hold proximal tibia while contralateral hand dorsiflexes and externally rotates foot, 3-0 nylon for skin with horizontal mattress stitches, in diabetics or patients with high risk for skin breakdown, use modified Allgower-Donati stitch to reduce tension on skin, advance weight-bearing status in CAM boot, if syndesmotic screw(s) placed need to be non-weightbearing, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, 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, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), identify joint involvement and articular step-off (>25%, >2mm requires ORIF), rolls under chest and knees and bump under hip for neutral rotation, between FHL (tibial nerve) and peroneal muscles (SPN), lobster claw or pointed clamps with hand rotation to reduce fibular fracture, move to posterior malleolus and free up fragments, place buttress plate 1/3 tubular or T-plate over posterior malleolus, anterior to posterior screws and 1/3 tubular plate over fibula, perform Cotton test / external rotation stress test to determine if syndesmosis injured, 1 or 2 screws, 3.5/4.5mm, tricortical or quadricortical, 2 wks non-weight bearing in postmold sugartong splint, 4-6 wks in CAM boot with progression of weight bearing and range of motion exercises, identify amount of joint involvement and articular step-off (>25%, >2mm requires ORIF), posterior malleolus fractures <25% of joint surface and <2mm articular step-off can be treated non-operatively in short leg walking cast vs. cast boot, CT often needed to evaluate percentage of joint surface involved, identify ankle fracture pattern (Lauge-Hansen SA, SER, PA, PER) and associated injuries, need to evaluate syndesmotic injury with stress exam, stiffness of syndesmosis restored to 70% of normal with isolated posterior malleolus fixation alone, standard OR table with radiolucent end, c-arm from contralateral side perpendicular to table, monitor at foot of bed in surgeon direct line of site, 2.0/2.5mm drills, 2.7/3.5mm cortical screws, 4.0mm cancellous screws, 1/3 tubular plates (Synthes Small Fragment Set), prone with feet at the end of the bed, bump under hip to get limb into neutral rotation, thigh tourniquet placed while patient supine high on thigh before flipping prone, internervous plane between FHL (tibial nerve) and peroneal muscles (SPN), incision along posterior border of fibula, access fibula with posterior retraction of peroneals, access posterior malleolus with anterior retraction of peroneals, blunt dissection between FHL and peroneals, stack of blue towels under anterior ankle to elevate limb, mark out lateral malleolus, anterior and posterior borders of fibula, borders of Achilles, incision ~6-8cm in length along posterolateral border of fibula, 15 blade through skin then tenotomy scissors to spread subcutaneous tissue with minimal soft tissue stripping, identify SPN with more proximal fractures, take fascia down sharply over posterior border of fibula anterior to peroneal tendons, sharp dissection down to bone with subperiostel dissection at fracture edges, extraperiosteal dissection proximal and distal to fracture site with knife and wood handled elevator, clean out fracture site using freer to open fracture site, curettes, small rongeur, dental pick, and irrigation to remove hematoma and interposed soft tissue, use lobster clamp and pointed clamps to reduce fracture, use hand rotation and contralateral thumb to help guide fragments together, lobster clamp has good hold on bone while pointed clamps have a more fine-tuned feel for reduction, need to be perpendicular to vector of fracture line, place temporary kwires to provisionally fix fragments, identify interval between peroneals and FHL, identify FHL by flexing hallux and watching for muscle belly movement, need to protect and retract posterior tibial neurovascular bundle medial to FHL, place self retainers and incise periosteum over post mal with 15blade, clean fracture site as above with fibula, do not release PITFL off of fragment as this will destabilize syndesmosis and devitalize fragment, fracture should reduce with reduction of fibula, reduce with direct pressure pushing down onto fragment, two 3.5mm screws (2.5mm drill) anterior to posterior in T-plate distal, 2 screws proximal into distal tibia, check placement of plate and screws under fluoro, make sure screws are perpendicular to bone, do not want distal screws (typically 40mm) to protrude anterior and irritate tibialis anterior, 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 posterior aspect of fibula, place 2-3 3.5mm bicortical screws (2.5mm drill), most distal screw will likely be 4.0 cancellous since its close to joint and/or syndesmosis, check plate and screw positions with fluoro on AP and Lat views, reduction tenaculum is placed ~2cm above joint and lateral pull applied, opening of the syndesmosis on mortise view is indicative of a positive stress test, if increased opening of tibia-fibular overlap syndesmosis is injured, anterior-posterior instability exam is most sensitive for syndesmosis injury, formally open the anterior aspect of the syndesmosis (anterior to fibula), remove interposing tissue if preventing reduction, place Weber pointed clamp or large periarticular clamp across syndesmosis, one tine on medial tibia and other on lateral fibula, hold foot in neutral dorsiflexion andinspect syndesmosis from lateral incision, inspect syndesmosis from lateral incision to ensure anatomic reduction, use 2.5mm (or 3.5mm) long drill bit to drill across fibula into tibia, drill bit orientation parallel to joint 2-4cm above joint, drill bit is angled ~20-30 posterior to anterior due to fibular position in syndesmosis, obtain final AP, mortise, and lateral radiographs, irrigate wounds thoroughly and deflate tourniquet if used, deep fascial closure over plate with 0-vicryl, soft incision dressing followed by postmold sugartong splint with extra padding under heel for immobilization, remove splint and place in short-leg cast boot, non-weight bearing, can allow ROM if soft tissue is appropriate, advance weight-bearing if diabetic, insensate, or syndesmotic screws present, syndesmotic screws to stay in for at least 12 weeks, syndesmotic screws will loosen or break if maintained, superficial and deep infections (1-2%, up to 20% in diabetics), peroneal irritation from posterior fibula antiglide plating, iatrogenic injury to SPN during fibula exposure, PITFL, posterior tibial neurovascular bundle during FHL exposure. Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the . 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Undecided
PDF Ankle Syndesmotic Injury - Orthobullets The repair of a ruptured deltoid ligament is not necessary in ankle fractures. New masking guidelines are in effect starting April 24. Posterolateral Corner Injury - Knee & Sports - Orthobullets (0/3). 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 . There are several ways to classify tibia and fibula fractures. Login. 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. There are different types of fractures, which can also affect treatment and recovery. "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:
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. Please Login to add comment. Distal tibial physeal fractures in children that may require open reduction. Tibia and fibula fractures in soccer players. 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 . Fibula Fractures - Post - Orthobullets Correlation of interosseous membrane tears to the level of the fibular fracture. The tibia is much thicker than the fibula. Are you sure you want to trigger topic in your Anconeus AI algorithm? The fibula and tibia connect via an interosseous membrane, which attaches to a ridge on the medial surface of the fibula. Weber C Fractures : Wheeless' Textbook of Orthopaedics The superficial peroneal nerve also gives sensation to the dorsum of the foot. Etiology. We'll assume you're ok with this, but you can opt-out if you wish. The triangular shape of the fibula is dictated by the insertion points of the muscles on the shaft. High-energy fractures, such as those caused by serious car accidents or major falls, are more common in older children. Ulnar gutter splint/cast. identify joint involvement and articular step-off (>25%, >2mm requires ORIF) . Type of screw fixation for repairing the syndesmosis: Differences have not been found between syndesmotic screws that engage 3 or 4 cortices (, The position of the ankle when fixation is applied is not important, but the syndesmosis must be reduced anatomically (, The use of bioabsorbable screws may obviate the need for screw removal (. 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. Pearls/pitfalls. The RICE protocol, with elastic wrap compression and pain medication, may be sufficient. 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. Follow-up/referral. Lauge Hansen classification: - classification: - C: fibula fracture above syndesmosis. Ankle Fractures - Trauma - Orthobullets Talofibular sprain or distal fibular avulsion, 1. bypass fracture, likely adjacent joint (i.e. B2 w/ medial lesion (malleolus or ligament) B3 w/ a medial lesion and fracture of posterolateral tibia. The deep peroneal nerve is responsible for sensation over the first dorsal webspace. Located posterolaterally to the tibia, it is much smaller and thinner. 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. seen with SER-type fracture patterns, AITFL avulsion of anterior tibial margin (tibial Weber classification of ankle fractures - Radiopaedia Located posterolaterally to the tibia, it is much smaller and thinner. Open fractures of the tibia are common among children and adults. Anteroposterior (A) and lateral (B) radiographic evaluation of the entire length of the fibula is essential to avoid missing a Maisonneuve fracture and the associated syndesmotic injury. Physical examination shows point tenderness and swelling in the area of fracture. Weber B: Lateral Malleolus Frx - Wheeless' Textbook of Orthopaedics Patients are followed at 1-month intervals with plain radiographs until the fractures are healed.