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. seen with SER-type fracture patterns, AITFL avulsion of anterior tibial margin (tibial (1/3), Level 3 Sometimes they may also involve the fracture of the growth plate (physis) located at each end of the tibia. The fibula is a slender bone that lies posterolaterally to the tibia. 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. 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. It's possible to fracture the fibula by placing too much pressure on it over and over again. prior total knee arthroplasty). Are you sure you want to trigger topic in your Anconeus AI algorithm? One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this contrasts with the treatment of lateral malleolus fractures, which, although it is part of the fibula, technically, are categorized as ankle fractures and, therefore, have different treatment principles. The tibia is much thicker than the fibula. 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 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). may be done supine with bump under affected limb or in lateral position. muscles of the posterior compartment ( tibial nerve) Approach. The pain may begin gradually. Fibular fractures in adults are typically due to trauma. This type of fracture usually results from high-energy trauma or penetrating wounds. Wang Q, Whittle M, Cunningham J, et al. 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. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. Significant periosteal stripping and soft tissue injury, Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury. Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. Are you sure you want to trigger topic in your Anconeus AI algorithm? Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Orthobullets Team Trauma - Ankle Fractures; Listen Now 38:12 min. Are you sure you want to trigger topic in your Anconeus AI algorithm? They are also called tibial plafond fractures. However, there is a risk of full or partial early closure of the growth plate. Tibia and fibula fractures are characterized as either low-energy or high-energy. 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. Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals. Long-distance runners and hikers are at risk for stress fractures. The fibula and tibia connect via an interosseous membrane, which attaches to a ridge on the medial surface of the fibula. Ulnar side of hand. Tibia and fibula are the two long bones located in the lower leg. Epidemiology of fractures in England and Wales. Medial malleolus transverse fracture or disruption of deltoid ligament, 3. 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. Isolated fibular fractures comprise the majority of ankle fractures in older women, occurring in approximately 1 to 2 of every 1000 White women each year [ 1 ]. Rarely, a fracture of the fibula may be. Tornetta P, III, Spoo JE, Reynolds FA, et al.
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