Nonsurgical Treatment. Fibula Fracture - TeachMe Orthopedics The interosseus membrane is the stout connection between the tibia . Diaphyseal tibial fractures are the most common long bone fracture. Stress Fractures of the Fibula . Are you sure you want to trigger topic in your Anconeus AI algorithm? The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. Fractures of the proximal head and neck of the fibula are associated with substantial damage to the knee (. Fibula fractures, including ankle fractures, are among the most commonly encountered fractures in orthopaedics (. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. Numbness or paresthesias may arise if damage to the peroneal nerve has occurred. It is the main weight-bearing bone of the two. There are different types of fractures, which can also affect treatment and recovery. 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. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. 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. The deep peroneal nerve innervates the musculature of the anterior compartment and is responsible for the dorsiflexion of the foot and toes. This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. Pediatric Distal Tibial Fracture - Wheeless' Textbook of Orthopaedics One of the common types in children is the distal tibial metaphyseal fracture. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. (1/3), Level 3 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. A common result of damage to the deep peroneal nerve is drop foot, in which there is a loss of the capacity to dorsiflex the foot. Patients with fibular shaft or head fractures generally present with tenderness and swelling in the area of injury. This type of injury is known as a stress fracture. Below are some of the most common tibia and fibula fractures that occur in children. Tibia and fibula fractures are characterized as either low-energy or high-energy. 2023 Lineage Medical, Inc. All rights reserved. Rarely, a fracture of the fibula may be. 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. A physical examination and X-rays are used to diagnose tibia and fibula fractures. Ulnar side of hand. 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. These fractures are usually transverse (across) or oblique (slanted) breaks in the bone. seen with SER-type fracture patterns, AITFL avulsion of anterior tibial margin (tibial may be done supine with bump under affected limb or in lateral position. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con However, there is a risk of full or partial early closure of the growth plate. If a medial malleolar fracture is present, it should be repaired with open fixation. 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). Weber C Fractures : Wheeless' Textbook of Orthopaedics 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. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint, 4. if skin cannot be closed, vac-assisted closure should be considered in short-term. There is very limited mobility between this syndesmosis. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. It is the main weight-bearing bone of the two. There are three types of tibial shaft fractures: These fractures occur at the ankle end of the tibia. Or an external fixator may be used to surgically repair the wound. Approach to the Fibula - Approaches - Orthobullets 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. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: Preparation. (0/3), Level 1 Tibia and fibula fracturesare characterized as either low-energy or high-energy. 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. 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 (. 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. Are you sure you want to trigger topic in your Anconeus AI algorithm? PDF Ankle Syndesmotic Injury - Orthobullets Surgery may also be needed depending on the wound size, amount of tissue damage and any vascular (circulation) problems. Tornetta P, III, Spoo JE, Reynolds FA, et al. Correlation of interosseous membrane tears to the level of the fibular fracture. B2 w/ medial lesion (malleolus or ligament) B3 w/ a medial lesion and fracture of posterolateral tibia. Boden BP, Lohnes JH, Nunley JA, et al. Position. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. It's possible to fracture the fibula by placing too much pressure on it over and over again. Stromsoe K, Hoqevold HE, Skjeldal S, et al. 356 plays. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. For prognostic reasons, severely comminuted, contaminated barnyard injuries, close-range shotgun/high-velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been included in the grade III group. 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). The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. bypass fracture, likely adjacent joint (i.e. The tibia is much thicker than the fibula. These fractures occur in the knee end of the tibia and are also called tibial plateau fractures. Fibula Fracture: Types, Symptoms, and Treatment - Verywell Health Epidemiology of fractures in England and Wales. Tibia and fibula fractures can be treated with standard bone fracture treatment procedures. The fibula and tibia connect via an interosseous membrane, which attaches to a ridge on the medial surface of the fibula. Long-distance runners and hikers are at risk for stress fractures. van Staa TP, Dennison EM, Leufkens HGM, et al. The RICE protocol, with elastic wrap compression and pain medication, may be sufficient. Located posterolaterally to the tibia, it is much smaller and thinner. Q: Do syndesmotic screws require removal? Proper . (2/3), Level 4 2023 Lineage Medical, Inc. All rights reserved. Fibula fractures occur around the ankle, knee, and middle of the leg. The treatment of an open tibial fracture starts with antibiotics and a tetanus shot to address the risk of infection. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Etiology. Obtain AP and lateral views of the knee to look for associated injury to the knee. Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. Posterolateral Corner Injury. The treatment depends on the severity of the injury and age of the child. proximal 1/3 tibia fractures account for 5-10% of tibial shaft fractures. Transverse comminuted fracture of the fibula above the level of the syndesmosis, 2. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Summary. Splints and Casts: Indications and Methods | AAFP 2023 Lineage Medical, Inc. All rights reserved. A splint or cast may be applied to increase comfort but is not essential. Pronation - External Rotation (PER) 1. Fibular fractures may also occur as the result of repetitive loading and in this case they are referred to as stress fractures. Fracture of the proximal fibula indicative of syndesmotic injury. - frx above the syndesmotic result from external rotation or abduction forces that also disrupt. 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. Weber C fractures can be further subclassified as 6. The fibula is a slender bone that lies posterolaterally to the tibia. Posterior Malleolus and Fibula Fracture ORIF - Orthobullets Copyright 2023 Lineage Medical, Inc. All rights reserved. Fibula bone fracture is a common injury seen in the emergency room. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. This may lead to a growth arrest in the form of leg length discrepancy or other deformity. Weightbearing on the involved leg may be allowed as tolerated by the patient. Obtain AP and lateral views of the shafts of the tibia and fibula. Diagnosis is made with plain radiographs of the ankle. 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). Open fractures of the tibia are common among children and adults. Overtightening of the ankle syndesmosis: is it really possible? The fibula is a site of five muscles attachment. - C2 diaphyseal fracture of the fibula, complex. Fibula Fractures - PubMed Patients are followed at 1-month intervals with plain radiographs until the fractures are healed. Outcome after surgery for Maisonneuve fracture of the fibula. 12/11/2019. 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. With an associated knee injury, patients have pain and swelling of the knee joint. a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint. These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement. Proximal fibula fractures - OrthopaedicsOne Articles Read More, Copyright 2007 Lippincott Williams & Wilkins. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . The fibular shaft is an origin for multiple muscles of the leg, including musclesof the anterior compartment (extensor digitorum longus, extensor hallucis longus, peroneus tertius), the lateral compartment (peroneus longus, peroneus brevis), the superficial posterior compartment (soleus), and the deep posterior compartment (tibialis posterior and flexor hallucis longus). 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. 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. Approach to the Fibula - Approaches - Orthobullets Open reduction and internal fixation is the surgery that can be used to reposition and physically connect the bones in an open fracture. (0/3), Level 5 Diagnosis is made with plain radiographs of the ankle. Fibula shaft fractures - OrthopaedicsOne Articles Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. 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. counterpart of LeFortWagstaffe fracture), medial sided swelling, tenderness, and ecchymosis not sensitive for medial stability, palpate proximal fibula for Maisonneuve fracture, most appropriate stress radiograph to assess competency of deltoid ligament, foot dorsiflexed and ER with tibia stabilized, more sensitive to injury than medial tenderness, ecchymosis, or edema, gravity stress radiograph is equivalent to manual stress radiograph, difficult for patients to tolerate in acute setting, it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements, normal <6 mm on both AP and mortise views, bisection of line through tibial anatomical axis and line through tip of both malleoli, shortening of lateral malleoli fractures can lead to increased talocrural angle, talocrural angle is not 100% reliable for estimating restoration of fibular length, can also utilize realignment of the medial fibular prominence with the tibiotalar joint, 25% of surgeons would change operative technique after CT, assess for anteromedial impaction of tibial plafond and talar articular cartilage injury, axial and sagittal views most useful to assess posterior malleolus, size and shape of posterior malleolus fragment, evaluate for soft tissue or cartilaginous injuries, positive anterior drawer or talar tilt test, increased medial clear space or tibiofibular diastasis on stress view, inability or weakness with plantar flexion, increased resting dorsiflexion when prone with knees bent, Chaput fragment, Volkmann fragment, medial malleolus, central impaction, high energy with extensive soft tissue injury, 25% open, x-ray shows dislocation of talus from calcaneous or navicular bone, avulsion tip fractures of medial or lateral malleolus, bimalleolar or bimalleolar-equivalent fracture, posterior malleolar fracture with > 25% or > 2mm step-off, goal of treatment is stable anatomic reduction with restoration of mortise, see fracture patterns below for specific treatment, direct reduction of medial and lateral malleolus fractures, indirect reduction of posterior malleolus, facilitates direct reduction of posterior malleolus, common approach for fibula ORIF syndesmotic fixation, concomitant access to posterior fibula and posterior malleolus, access to medial malleolus and posterior malleolus, common approach for medial malleolus ORIF, prolonged recovery expected (2 years to obtain final functional result), anatomic reduction is considered most important factor for satisfactory outcome, ORIF superior to closed treatment of bimalleolar fractures, improved incisional perfusion with Allgwer-Donati sutures, proper braking response time (driving) returns to baseline at 9 weeks after surgery, braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of lower extremity, severe open fractures with gross contamination, poor soft tissue requiring close monitoring, lower risk of redislocation and skin complication in ankle fracture dislocation vs splint, isolated medial malleolus fracture without talar shift, deep deltoid inserts on posterior colliculus, good outcomes with >95% union rate for isolated injury, lag screw fixation stronger if placed perpendicular to fracture line, bicortical 3.5 mm fully-threaded screw (lag by technique) superior to unicortical 4.0 mm partially-threaded screw (lag by design), > 4-5 mm of medial clear space widening on stress views considered unstable, recent studies show deep deltoid intact with 8-10 mm of widening on stress view, open reduction and internal fixation (ORIF), presence of talar shift on static or stress view (bimalleolar equivalent), one-third tubular or anatomic distal fibular plate, stiffest fixation construct for the fibula is a locking plate, posterior antiglide plating is biomechanically superior to lateral plate, disadvantage of peroneal tendon irritation if plate too distal, newer implants have improved axial and rotational control with distal/proximal fixation, useful for poor soft-tissue envelopes or high risk for wound-healing complication, similar outcomes with operative and non-operative treatment if stable mortise, Bimalleolar-Equivalent Fracture (deltoid ligament tear with fibular fracture), low demand and unable to tolerate surgery, lateral malleolus fracture with talar shift (static or stress view), assess syndesmotic stability after fixation of lateral malleolus, not necessary to repair medial deltoid ligament, explore medially if unable to reduce mortise and deltoid ligament potentially interposed, lower rate of nonunion and fracture displacement with operative treatment, Bimalleolar (MEDIAL AND LATERAL) Fracture, low demand and unable to undergo surgical intervention, any displacement or talar shift (static or stress view), size should be calculated on CT since plain radiographs are unreliable, interval between FHL and peroneal tendons, common approach since posterior malleolus fractures are frequently posterolateral, decision of approach will depend on location of fracture, degree of displacement, and need for fibular fixation, stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus vs 40% with isolated, PITFL may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation, stress examination of syndesmosis still required after posterior malleolar fixation, 40-90% of distal third spiral tibia fractures have an associated posterior malleolus fracture, rare fracture-dislocation of ankle where fibula is entrapped behind tibia and is irreducible, posterolateral ridge of the distal tibia hinders reduction of the fibula, open reduction of fibula and internal fixation is required, fracture-dislocation of the ankle due to hyperplantarflexion, main feature is a vertical shear fracture of the posteromedial tibial rim, double cortical density at the inferomedial tibial metaphysis, ORIF of posterior malleolus with antiglide plating, primary closure at index procedure can be performed in appropriately-selected grade I, II, and IIIA open fractures in otherwise healthy patients without gross contamination, higher incidence with higher fibula fractures, fixation usually not required when fibula fracture within 4.5 cm of plafond, measure tibiofibular clear space 1 cm above joint, abduction/external rotation stress of dorsiflexed foot, lateral stress radiograph has greater interobserver reliability than an AP/mortise stress film, instability of the syndesmosis is greatest in the anterior-posterior direction, patient placed in lateral decubitus position, similar effectiveness to manual ER stress test, bone hook around fibula used to pull while placing counter traction on tibia, tibiofibular clear space (AP) greater than 5 mm, length and rotation of fibula must be accurately restored, "Dime sign"/Shentons line to determine length of fibula, fixing lateral and/or posterior malleolus first my obviate need for syndesmotic fixation, outcomes are strongly correlated with anatomic reduction, maximum dorsiflexion not required during screw placement (over-tightening), open reduction required if closed reduction unsuccessful or questionable, one or two cortical screw(s) or suture-button devices 2-4 cm above joint, angled posterior to anterior 20-30 degrees (fibula posterior to tibia), suture button has lower rate of malreduction and reoperation rate than screws, no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year, outcome may be worse with maintenance of intact screws, screws should be maintained in place for at least 8-12 weeks, must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation, any postoperative malalignement or widening should be treated with open debridement, reduction, and fixation, Diabetic Ankle Fractures (with or without Neuropathy), poor circulation impairs wound and fracture healing, multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury), tibiotalar Steinmann pins or hindfoot nailing, augment with intramedullary fibula K-wires, stiffer, more rigid fibular plates (instead of 1/3 tubular plates), maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients), largest risk factor for diabetic patients is presence of, articular impaction of tibial plafond in SAD injuries should be addressed at time of surgery, corrective osteotomy requires obtaining anatomic fibular length and mortise correction for optimal outcomes, Loss of dorsiflexion with posterior fixation, rare with anatomic reduction and fixation, very common in "log-splitter" type injuries (trans-syndesmotic fracture-dislocations in which the talus is driven into the distal tibiofibular articulation), superficial peroneal nerve injury (10-15%), At risk with lateral approach to distal fibula, posterolateral, and anterior/anterolateral approaches, Two terminal nerve branches that innervate dorsum of the foot, protruding screw head in most distal hole of fibula plate, at risk with posterior medial malleolus screw placement, Excellent for stable ankle fractures treated nonoperatively, Outcomes following operative treatment generally very favorable, 90% mild/no ankle pain with minimal limitations and near full functional recovery at 1 yr, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries.

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