Ankle Fractures - Pediatric - Pediatrics - Orthobullets Figure 3 Normal syndesmotic relationships include a tibiofibular clear space (open arrows) <6 . Tibia and fibula fractures can be treated with standard bone fracture treatment procedures. Diagnosis is made with plain radiographs of the ankle. rotation about a planted foot and ankle, accounts for 35-40% of overall tibial growth and 15-20% of overall lower extremity growth, growth continues until 14 years in girls and 16 years in boys, closure occurs during an 18 month transitional period, pattern of closure occurs in a predictable pattern: central > anteromedial > posteromedial > lateral, closure occurs 12-24 months after closure of distal tibial physis, Ligaments (origins are distal to the physes), primary restraint to lateral displacement of talus, anterior inferior tibiofibular ligament (AITFL), extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle), plays an important role in transitional fractures (Tillaux, Triplane), posterior inferior tibiofibular ligament (PITFL), extends from posterior aspect of lateral distal tibial epiphysis (Volkmanns tubercle) to posterior aspect of distal fibula, extends from posterior distal fibula across posterior aspect of distal tibial articular surface, functions as posterior labrum of the ankle, Fracture extends through the physis and exits through the metaphysis, forming a Thurston-Holland fragment, Fracture extends through the physis and exits through the epiphysis, Seen with medial malleolus fractures and Tillaux fractures, Fracture involves the physis, metaphysis and epiphysis, Can occur with lateral malleolus fractures, usually SH I or II, Seen with medial malleolus shearing injuries and triplane fractures, Can be difficult to identify on initial presentation (diagnosis is usually made when growth arrest is seen on follow-up radiographs), Results from open injury (i.e. Copyright 2023 Lineage Medical, Inc. All rights reserved. This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. At Another Johns Hopkins Member Hospital: Tibia fractures are the most common lower extremity fractures in children. It may include some of the following approaches, used either alone or in combination: An open fracture occurs when the bone or parts of the bone break through the skin. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this con 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. B2 w/ medial lesion (malleolus or ligament) B3 w/ a medial lesion and fracture of posterolateral tibia. Fibula Fracture: Types, Symptoms, and Treatment - Verywell Health Fibular Avulsion Fracture - FootEducation Long-distance runners and hikers are at risk for stress fractures. Obtain 3 views of the ankle (AP, lateral, and mortise) to look for ankle fracture or syndesmotic disruption. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. Are you sure you want to trigger topic in your Anconeus AI algorithm? Weber B: Lateral Malleolus Frx - Wheeless' Textbook of Orthopaedics The treatment of an open tibial fracture starts with antibiotics and a tetanus shot to address the risk of infection. A CT scan may be required to further characterize the fracture pattern and for surgical planning. Wang Q, Whittle M, Cunningham J, et al. A retrospective study of two hundred . 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. The fibula is a slender bone that lies posterolaterally to the tibia. Or an external fixator may be used to surgically repair the wound. Patients with isolated fibular shaft fractures are instructed to bear partial weight. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Epiphyseal fractures of the distal ends of the tibia and fibula. 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. Fractures of the fibula often involve a syndesmotic injury (called Maisonneuve fractures). There will be a pain in the lower leg on weight-bearing although . accounts for 25-40% of all physeal injuries (second most common), accounts for 5% of all pediatric fractures, pediatric ankle fractures are a common injury that includes, twisting injury, i.e. They are also called tibial plafond fractures. open 1/3 tibial shaft fracture with placement of proximal 1/3 tibia and calcaneus/metatarsal pins to span fracture), construct stiffness increased with larger pin diameter, number of pins on each side of fracture, rods closer to bone, and a multiplanar construct, incision from inferior pole of patella to just above tibial tubercle, identify medial edge of patellar tendon, incise, insert guidewire as detailed below and ream, can lead to valgus malalignment in proximal 1/3 tibial fractures, helps maintain reduction when nailing proximal 1/3 fractures, can damage patellar tendon or lead to patella baja (minimal data to support this), semiextended medial or lateral parapatellar, used for proximal and distal tibial fractures, skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon, knee should be in 5-30 degrees of flexion, choice to go medial or lateral is based of mobility of patella in either direction, identify starting point and ream as detailed below, suprapatellar nailing (transquadriceps tendon), easier positioning if additional instrumentation needed, more advantageous for proximal or distal 1/3 tibia fractures, starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view, in proximal 1/3 tibia fractures starting point should cheat laterally to avoid classic valgus/procurvatum deformity, ensure guidewire is aligned with tibia in coronal and sagittal planes as you insert, opening reamer is placed over guidewire and ball-tipped guidewire can then be passed, spanning external fixation (ie. If a fibula fracture is associated with a. All Rights Reserved. C3: proximal fracture of the fibula. muscles of the posterior compartment ( tibial nerve) Approach. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Repeated cleanings prior to closing the wound may be used instead. may be done supine with bump under affected limb or in lateral position. Read More, Copyright 2007 Lippincott Williams & Wilkins. 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. Treatment for tibia and fibula fractures ranges from casting to surgery, depending on the type and severity of the injury. van Staa TP, Dennison EM, Leufkens HGM, et al. Q: Do syndesmotic screws require removal? isolated but, in general, the force required to fracture the fibula. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. Repair of the deltoid ligament tear is not believed to be necessary (. Weber C Fractures : Wheeless' Textbook of Orthopaedics Although tibia and fibula shaft fractures are amongst the most common long bone fractures, there is little literature citing the incidence of isolated fibula shaft fractures. The fibula is a site of five muscles attachment. Both the posterior and medial malleolus arepart of the distal end of the tibia. Please . Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. Fractures of the proximal head and neck of the fibula are associated with substantial damage to the knee (. 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. Please Login to add comment. There are three types of tibial shaft fractures: These fractures occur at the ankle end of the tibia. In rare cases, external fixation or ORIF is more appropriate depending on the location and orientation of the fracture. Additionally, lateral collateral ligament of the knee originates from the lateral epicondlye of the femur to insert on the superior portion of the fibular head and is the .