Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Fibula Fracture

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.
    • 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.
Epidemiology
Incidence
Fibula fractures, including ankle fractures, are among the most commonly encountered fractures in orthopaedics.
 
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.
  • 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
    • 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.
    • Repair of the deltoid ligament tear is not believed to be necessary.
    • The need for syndesmotic screw fixation should be determined by the use of an intraoperative external rotation stress test under fluoroscopy.
    • 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.
      • 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.
    • The use of bioabsorbable screws may obviate the need for screw removal.
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.
 
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.
 
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.
 
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.

1 comment to Fibula Fracture

  • Jon

    I was shot twice in Vietnam on 27 Apr 1969. An AK 47 7.62 mm round blew a section of bone out of the distal fibula after it hit the middle of my lower ankle and exited out below the calf. There was some 1-2 inches of bone missing for many years with only calcium or tiny bone fragments sitting between the bone and outward by the outer right ankle/lower leg. Well, the non union continues into 2000 and sometime around 2010 an Xray confirmed healed FX. The problem is the entire ankle is very painful as the bone angles outward where it was broken all those years. Morphine in large doses will not touch the pain. Back in 1969 ortho MD’s stated one does not need the distal 1/3 fibula. I was hit at the same time with a 12.7mm through the biceps femoris/hamstring group and the huge bullet exited the pelvic area missing the femur and artery.