The superficial peroneal nerve also gives sensation to the dorsum of the foot. These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement. 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. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint. In 1 recent study, shin guards did not seem to prevent tibia and fibula fractures in soccer players (14). The interosseus membrane is the stout connection between the tibia . Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. It is the main weight-bearing bone of the two. Please . The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. Tibia and Fibula Fractures | Johns Hopkins Medicine Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. 12/11/2019. Obtain AP and lateral views of the knee to look for associated injury to the knee. 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. C2: diaphyseal fracture of the fibula, complex. The fibula is a slender bone that lies posterolaterally to the tibia. Are you sure you want to trigger topic in your Anconeus AI algorithm? Fibular Fracture - Physiopedia At Another Johns Hopkins Member Hospital: Tibia fractures are the most common lower extremity fractures in children. Posterolateral Corner Injury - Knee & Sports - Orthobullets 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). 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. Approach to the Fibula - Approaches - Orthobullets Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. A lateral malleolus fracture is a fracture of the lower end of the fibula. These types include: lateral malleolus . - C1 diaphyseal fracture of the fibula, simple. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus, 4. With an associated knee injury, patients have pain and swelling of the knee joint. Wang Q, Whittle M, Cunningham J, et al. Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury ( distal tibiofibular syndesmosis , deltoid ligament) and/or fracture of the medial malleolus. Stress Fractures of the Fibula . Tibia and fibula fracturesare characterized as either low-energy or high-energy. 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. 2023 Lineage Medical, Inc. All rights reserved, 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. There are different types of fractures, which can also affect treatment and recovery. Both the posterior and medial malleolus arepart of the distal end of the tibia. Lateral short oblique fibula fracture (anteroinferior to posterosuperior), 3. Medial malleolus transverse fracture or disruption of deltoid ligament, 3. C1: diaphyseal fracture of the fibula, simple. Common proximal tibial fractures include: This type of fracture takes place in the middle, or shaft (diaphysis), of the tibia. Pearls/pitfalls. (0/3). The following article will focus on fractures of the fibula that are proximal to the ankle joint and the treatment of such fractures. 2023 Lineage Medical, Inc. All rights reserved. Fibular Avulsion Fracture - FootEducation Fibula Fracture: Treatment & Healing Process - STARS Physical Therapy Boden BP, Lohnes JH, Nunley JA, et al. Copyright 2023 Lineage Medical, Inc. All rights reserved. Outcome after surgery for Maisonneuve fracture of the fibula. Pediatric Distal Tibial Fracture. Figure 3 Normal syndesmotic relationships include a tibiofibular clear space (open arrows) <6 . 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. 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). If a fibula fracture is associated with a. Accept Wounds may be treated with vacuum-assisted closure. This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. Orthobullets Team Trauma - Ankle Fractures; Listen Now 38:12 min. Weber C Fractures : Wheeless' Textbook of Orthopaedics Fracture of the proximal fibula indicative of syndesmotic injury. Open fractures of the tibia are common among children and adults. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. Fibula fractures - UpToDate There will be a pain in the lower leg on weight-bearing although . The pain may begin gradually. Diagnosis is made with plain radiographs of the ankle. Are you sure you want to trigger topic in your Anconeus AI algorithm? Epidemiology of fractures in England and Wales. Patients require pain medicine as appropriate. Weber classification of ankle fractures - Radiopaedia Tibial Shaft Fractures - Trauma - Orthobullets Indications. It is caused by a pronation-external rotation mechanism. The RICE protocol, with elastic wrap compression and pain medication, may be sufficient. Tibia and fibula fractures can be treated with standard bone fracture treatment procedures. (0/3), Level 2 usually associated with an injury to the medial side ORIF of fibula fractures; resection of fibula; excision of fibula bone lesions; Internervous plane: Between . Fractures of the fibula often involve a syndesmotic injury (called Maisonneuve fractures). low energy (fall from standing, twisting, etc) result of indirect, torsional injury. Follow-up/referral. 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 . Rarely, a fracture of the fibula may be. 5.0 (1) Login. One of the common types in children is the distal tibial metaphyseal fracture. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. Incision. C3: proximal fracture of the fibula. 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. Low-energy, nondisplaced (aligned) fractures, sometimes called toddlers fractures, occur from minor falls and twisting injuries. A splint or cast may be applied to increase comfort but is not essential. 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. - frx above the syndesmotic result from external rotation or abduction forces that also disrupt. make up about 17% of all lower extremity fractures, account for 4% of all fractures seen in the Medicare population, older patients - falls, lower energy mechanisms, proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures, low energy (fall from standing, twisting, etc), spiral fracture pattern with fibula fracture at a different level, high association of posterior malleolus fractures with spiral distal tibia fractures, more likely to be associated with a lower degree of soft tissue injury, high energy fx (MVA, fall from height, athletics, etc), leads to wedge or short oblique fracture that may have significant comminution with fibula fracture at same level, more likely to be associated with severe soft tissue injury, must rule out extension into tibial plateau on plain films or CT scan, high risk for valgus/procurvatum deformity, higher rates of ankle injury seen with distal 1/3 tibia fracture and spiral fracture pattern, posterior malleolus most common associated ankle injury which, in some cases, may affect syndesmotic stability, extension into or adjacent to tibial plafond may require separate/additional fixation and are managed differently than tibial shaft fractures, severity of muscle injury has highest impact on eventual need for amputation, more common in diaphyseal tibial shaft fractures than proximal or distal tibia fractures, 8.1% risk in diaphyseal fractures, compared to proximal (1.6%) and distal (1.4%) fractures, can occur even in the setting of an open fracture, all four compartments must be examined. 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 . Pediatric Distal Tibial Fracture - Wheeless' Textbook of Orthopaedics Significant periosteal stripping and soft tissue injury, Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury. Fibular fractures in adults are typically due to trauma. prior total knee arthroplasty). 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). if skin cannot be closed, vac-assisted closure should be considered in short-term. Weber C fractures can be further subclassified as 6. Stromsoe K, Hoqevold HE, Skjeldal S, et al. Read More, Copyright 2007 Lippincott Williams & Wilkins. This may lead to a growth arrest in the form of leg length discrepancy or other deformity. Are you sure you want to trigger topic in your Anconeus AI algorithm? Weber B: Lateral Malleolus Frx - Wheeless' Textbook of Orthopaedics 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Undecided Etiology. Fibula Fractures - Post - Orthobullets The proximal fibula is the insertion point for the biceps femoris posterolaterally, the soleus posteriorly, and the peroneus longus and extensor digitorum longus anteiorly. Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con The treatment depends on the severity of the injury and age of the child. Proper . 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). There are several ways to classify tibia and fibula fractures. Position.