These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement. traveling traction), placed in metaphyseal segment at the concavity of the deformity, posteriorly placed blocking screw in proximal fragment and laterally placed blocking screw in the metaphyseal fragment help direct the nail more centrally, avoiding valgus/procurvatum deformities, increase biomechanical stability of bone/implant construct by 25%, not associated with increased infections, wound complications, and nonunion compared to closed-nailing techniques, ensure fracture is reduced before reaming, overream by 1.0-1.5mm to facilitate nail insertion, confirm guide wire is appropriately placed prior to reaming, should be "center-center" in the coronal and sagittal planes distally at the physeal scar, anterior aspect of nail should be lined up with axis of tibia when inserting nail - typically should line up with 2nd metatarsal in absence of tibial deformity, statically lock proximal and distally for rotational stability, no indication for dynamic locking acutely, number of interlocking screws is controversial, two proximal and two distal screws in presence of <50% cortical contact, consider 3 interlock screws in short segment of distal or proximal shaft fracture, prefer multiplanar screw fixation in these short segments, lateral may have more soft tissue interference but may be preferred in setting of soft tissue/wound issues, generally, minimally invasive plating is used to preserve soft tissues, plate attached to external jig to allow for percutaneous insertion of screws, must ensure appropriate contour of plate to avoid malreduction, higher risk for wound issues, particularly in open fractures, superficial peroneal nerve (SPN) commonly at risk laterally, below knee amputation (BKA) vs. above knee amputation (AKA) based on degree of soft tissue damage, standard BKA vs. ertl/bone block technique, infrapatellar nailing with patellar tendon splitting and paratendon approach, suprapatellar nailing may have lower rate of anterior knee pain, more common if nail left proud proximally, lateral radiograph is best radiographic views to evaluate proximal nail position, pain relief unpredictable with nail removal, all tibial shaft fractures - between 8-10%, higher in proximal 1/3 tibia fractures - up to 50%, patellar tendon pulls proximal fragment into extension, while hamstring tendons and gastrocnemius pull the distal fragment into flexion (procurvatum), distal 1/3 fractures have a higher rate of valgus malunion with IM nailing compared to plating, definitive management with casting or external fixation, most common deformity is varus with nonsurgical management, varus malunion may place patient at risk for ipsilateral ankle pain and stiffness, starting point too medial with IM nailing, adequate reduction, proper start point when nailing, if malalignment is noted immediately after surgery, return to operating room is appropriate with removal of nail, reduction and nail reinsertion, if malunion is appreciated at later followup, eventual nail removal and tibial osteotomy can be considered, most appropriate for aseptic, diaphyseal tibial nonunions, oblique tibial shaft fractures have the highest rate of union when treated with exchange nailing, consider revision with plating in metaphyseal nonunions, BMP-7 (OP-1) has been shown equivalent to autograft, often used in cases of recalcitrant non-unions, compression plating has been shown to have a 92-96% union rate after open tibial fractures initially treated with external fixation, fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula, highest after IM nailing of distal 1/3 tibia fractures, increases risk of adjacent ankle arthrosis, should always assess rotation in operating room, obtain perfect lateral fluoroscopic image of knee, then rotate c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle, may have reduced risk with adjunctive fibular plating, LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity, saphenous nerve can be injured during placement of locking screws, transient peroneal nerve palsy can be seen after closed nailing, EHL weakness and 1st dorsal webspace decreased sensation, usually nonoperatively with variable recovery expected, severe soft tissue injury with contamination, longer time to definitive soft tissue coverage, may require I&D or eventual removal of hardware, use of wound vacuum-assisted closure does not decrease risk of infection, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. 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). One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con Are you sure you want to trigger topic in your Anconeus AI algorithm? 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. All Rights Reserved. There are several distinct portions of the fibula in terms of structure, including the head, neck, shaft, and the distal end termed the lateral malleolus. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . Damage to this nerve may result in deficits in those movements. (0/3). This type of injury is known as a stress fracture. Maisonneuve fractures with syndesmotic injury imply injury to the medial side of the ankle joint. These fractures are usually transverse (across) or oblique (slanted) breaks in the bone. 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). 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. 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. They account for 10 to 15 percent of all pediatric fractures. Are you sure you want to trigger topic in your Anconeus AI algorithm? Nielson JH, Sallis JG, Potter HG, et al. performed with the hip flexed 45, knee flexed 80, and foot is ER 15. Lateral short oblique fibula fracture (anteroinferior to posterosuperior), 3. Patients require pain medicine as appropriate. Weber C fractures can be further subclassified as 6. Overtightening of the ankle syndesmosis: is it really possible? The diagnosis is made by x-raying the ankle. Surgery may also be needed depending on the wound size, amount of tissue damage and any vascular (circulation) problems. The fibula is a slender bone that lies posterolaterally to the tibia. Physical examination shows point tenderness and swelling in the area of fracture. The fibula fracture may have several different patterns: The shaft of the fibula tends to heal well on its own because it is encompassed completely by vascularized muscle. - C2 diaphyseal fracture of the fibula, complex. There is very limited mobility between this syndesmosis. van Staa TP, Dennison EM, Leufkens HGM, et al. 2023 Lineage Medical, Inc. All rights reserved. 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.