High Yield Topics

Fibula Fracture

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Fibula Fracture

Fibula Fracture
Simon C. Mears MD, PhD
Nicholas Ahn MD
Basics
Description
  • Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal.
  • Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint.
  • Rarely, a fracture of the fibula may be
    isolated but, in general, the force required to fracture the fibula
    also breaks other structures in the leg.
  • Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see “Ankle Fracture” chapter).
  • Fractures of the fibular shaft occurring without ankle injury nearly always are associated with tibial shaft fractures.
  • Fractures of the proximal head and neck of the fibula are associated with substantial damage to the knee (1).
    • These fractures may be isolated, caused
      by a direct blow to the area, or caused by an avulsion injury at the
      insertion of the biceps femoris tendon or LCL.
  • Fractures of the fibula often involve a syndesmotic injury (called “Maisonneuve fractures”).
    • Damage along the medial aspect of the
      ankle joint by external rotation forces may be associated with rupture
      of the deltoid and tibiofibular ligaments, which may, in turn, cause a
      tear in the interosseous membrane between the shafts of the tibia and
      fibula.
    • As this tear progresses up the
      interosseous membrane, all the forces are placed more proximally along
      the fibula at the area where the tear ends, causing a proximal fibula
      fracture (2).
Epidemiology
Incidence
Fibula fractures, including ankle fractures, are among the most commonly encountered fractures in orthopaedics (3).
Etiology
  • Trauma (direct blow or gunshot wound)
  • Falls
  • Missteps
  • Sports injuries
Associated Conditions
  • Fractures of the tibial shaft
  • Compartment syndrome of the leg
  • Tibial plateau fractures
  • MCL injury of the knee
  • LCL injury of the knee
  • Biceps femoris tendon injury
  • Common peroneal nerve palsy
  • Interosseous membrane rupture
  • Deltoid ligament of the ankle injury
  • Medial malleolar ankle fracture
Classification
  • Proximal fracture
  • Midshaft fracture
  • Distal (ankle) fracture
Diagnosis
Signs and Symptoms
  • Patients with fibular shaft or head fractures generally present with tenderness and swelling in the area of injury.
    • Numbness or paresthesias may arise if damage to the peroneal nerve has occurred.
  • With an associated knee injury, patients have pain and swelling of the knee joint.
  • Maisonneuve fractures present with
    swelling and pain, not only proximally in the area of the fibula
    fracture, but also about the medial aspect of the ankle joint.
Physical Exam
  • Physical examination shows point tenderness and swelling in the area of fracture.
  • Always assess stability and medial
    tenderness of the ankle because a possible deltoid tear with a proximal
    fibula fracture may be present (Maisonneuve fracture).
  • Always assess the stability and
    tenderness of the knee, particularly in proximal fibula fractures,
    including examination of all ligaments.
Tests
Lab
No serum laboratory tests are indicated.
Imaging
  • Radiography:
    • Obtain AP and lateral views of the shafts of the tibia and fibula.
    • Obtain AP and lateral views of the knee to look for associated injury to the knee.
    • Obtain 3 views of the ankle (AP, lateral, and mortise) to look for ankle fracture or syndesmotic disruption.
Pathological Findings
  • The fibula fracture may have several different patterns:
    • Spiral
    • Transverse
    • Comminuted
  • Fractures secondary to tumors are rare.
Differential Diagnosis
  • Muscle tears (gastrocnemius, soleus)
  • Tendon rupture
  • Syndesmotic injury
  • Knee or ankle injury
Treatment
General Measures
  • Isolated fibular shaft fractures that do
    not involve the ankle or knee are relatively unimportant because the
    fibula supports only 17% of body weight and is not essential to
    stability (4).
  • The shaft of the fibula tends to heal well on its own because it is encompassed completely by vascularized muscle.
  • A splint or cast may be applied to increase comfort but is not essential.
    • The RICE protocol, with elastic wrap compression and pain medication, may be sufficient.
  • Pain and swelling usually are diminished
    in 1–2 weeks, at which time the patient is allowed to return to regular
    activity as tolerated.
  • Full healing usually is accomplished by 6–8 weeks.
  • Fractures that involve syndesmotic injury or ankle or knee fracture often require surgical treatment.
Activity
Weightbearing on the involved leg may be allowed as tolerated by the patient.
Special Therapy
Physical Therapy
  • Patients with isolated fibular shaft fractures are instructed to bear partial weight.
  • Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals.
Medication
First Line
Patients require pain medicine as appropriate.
Surgery
  • If a fibula fracture is associated with a
    tibial shaft fracture or a tibial plateau fracture, then the tibial
    fracture is repaired, and the fibula usually heals without fixation.
  • For distal tibial fractures, fixation of the fibula:
    • May aid in realignment or length restoration of the tibial fracture
    • Increases the stability of the tibial fracture repair (5,6)
    • Is performed with a 3.5-mm compression plate
  • Maisonneuve fractures with syndesmotic injury imply injury to the medial side of the ankle joint.
    • These fractures should be treated operatively with open plating of the fibula fracture and syndesmotic screw placement.
    • If a medial malleolar fracture is present, it should be repaired with open fixation.

      • P.137


    • Repair of the deltoid ligament tear is not believed to be necessary (7).
    • The need for syndesmotic screw fixation
      should be determined by the use of an intraoperative external rotation
      stress test under fluoroscopy (8).
    • Type of screw fixation for repairing the syndesmosis:
      • Choice is debated.
      • Differences have not been found between syndesmotic screws that engage 3 or 4 cortices (9).
      • Debate also exists as to whether these
        screws should be removed or should remain in place indefinitely or
        until they break and require removal.
    • The position of the ankle when fixation is applied is not important, but the syndesmosis must be reduced anatomically (10).
    • The use of bioabsorbable screws may obviate the need for screw removal (11).
Follow-up
Disposition
Issues for Referral
Patients with tibia fractures, syndesmosis injuries, or ankle fractures should be referred to an orthopaedic surgeon.
Prognosis
Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (12,13).
Complications
  • Nonunion
  • Chronic pain
  • Malunion
  • Hardware pain or breakage
  • Compartment syndrome
Patient Monitoring
Patients are followed at 1-month intervals with plain radiographs until the fractures are healed.
References
1. Bozkurt
M, Turanli S, Doral MN, et al. The impact of proximal fibula fractures
in the prognosis of tibial plateau fractures: a novel classification. Knee Surg Sports Traumatol Arthrosc 2005;13:323–328.
2. Nielson JH, Sallis JG, Potter HG, et al. Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68–74.
3. van Staa TP, Dennison EM, Leufkens HGM, et al. Epidemiology of fractures in England and Wales. Bone 2001;29:517–522.
4. Wang Q, Whittle M, Cunningham J, et al. Fibula and its ligaments in load transmission and ankle joint stability. Clin Orthop Relat Res 1996;330:261–270.
5. Egol
KA, Weisz R, Hiebert R, et al. Does fibular plating improve alignment
after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma 2006;20:94–103.
6. Kumar
A, Charlebois SJ, Cain EL, et al. Effect of fibular plate fixation on
rotational stability of simulated distal tibial fractures treated with
intramedullary nailing. J Bone Joint Surg 2003;85A:604–608.
7. Stromsoe K, Hoqevold HE, Skjeldal S, et al. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg 1995;77B:920–921.
8. Jenkinson
RJ, Sanders DW, Macleod MD, et al. Intraoperative diagnosis of
syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma 2005;19:604–609.
9. Hoiness
P, Stromsoe K. Tricortical versus quadricortical syndesmosis fixation
in ankle fractures: a prospective, randomized study comparing two
methods of syndesmosis fixation. J Orthop Trauma 2004;18:331–337.
10. Tornetta P, III, Spoo JE, Reynolds FA, et al. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg 2001;83A:489–492.
11. Thordarson
DB, Samuelson M, Shepherd LE, et al. Bioabsorbable versus stainless
steel screw fixation of the syndesmosis in pronation-lateral rotation
ankle fractures: a prospective randomized trial. Foot Ankle Int 2001;22:335–338.
12. Sproule JA, Khalid M, O’Sullivan M, et al. Outcome after surgery for Maisonneuve fracture of the fibula. Injury 2004;35:791–798.
13. Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 2005;19:102–108.
14. Boden BP, Lohnes JH, Nunley JA, et al. Tibia and fibula fractures in soccer players. Knee Surg Sports Traumatol Arthrosc 1999;7:262–266.
Miscellaneous
Codes
ICD9-CM
823.8 Fibula fracture
Patient Teaching
Patients are counseled that, although fibula fractures
heal well, tenderness and swelling may persist for several months after
injury.
Prevention
In 1 recent study, shin guards did not seem to prevent tibia and fibula fractures in soccer players (14).
FAQ
Q: Do syndesmotic screws require removal?
A:
The removal of screws after healing is controversial. Some surgeons
recommend routine removal to avoid breakage; others believe that screws
should be removed only if they become painful.

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