Fibular fractures

 

Weber Classification of fibular fractures

 

Weber A Weber B Weber c
Fracture distal to syndesmosis Fracture at level of syndesmosis Fracture above level syndesmosis

Stable - avulsion fracture

Stability depends on deltoid ligament

 

Stable - no increased medial clear space / deltoid ligament intact

Unstable - Increased medial clear space / deltoid ligament rupture

Unstable

 

Syndesmosis disrupted

Weber A Weber bweber b Weber C

 

Epidemiology

 

Court-Brown et al Acta Orthop Scand 1998

- 1500 ankle fractures

- 38% Weber A

- 52% Weber B

- 10% Weber C

 

4th most common fracture requiring surgery

 

Weber A fibular fracture

 

Definition

 

Fracture below level of syndesmosis

Fibular avulsion fracture

 

Management

 

Stable

Full weight bear

 

Weber B fibular Fracture

 

Definition

 

Fracture at level of syndesmosis

 

Supination-external rotation Type IV

 

Syndesmosis stable - management depends on deltoid ligament

 

Deltoid ligament assessment

 

Mortise view

- symmetrical space around mortise

- AP with 15 degrees internal rotation

 

Increased medial clear space / lateral talar shift / deltoid ligament injury

 

MortiseWeber BWeber B

 

Examination Xray Stress xray
Tender / bruising medially Increased medial clear space > 4 mm

 Gravity Stress View

- patient lies injured side down with cross table xray

- increased medial clear space

 

Stress xray

- lead gloves / valgus stress / painful

Medial bruising Ankle Fracture Weber B + Deltoid Ligament

Weber B

 

Stenquist et al Injury 2020

- presence of medial tenderness and deltoid ligament injury

- limited ability of tenderness to determine complete deltoid ligament instability

 

van Leeuwen et al Arch Orthop Trauma Surg 2022

- systematic review of predicting deltoid ligament rupture

- ultrasound: sensitivity 100%, specificity 90 - 100%

- gravity stress: sensitivity 70-100%, specificity 88-92%

- medial clear space / manual stress / MRI: 65 - 88%

 

Stable Weber B / intact deltoid ligament

 

Weber BWeber B

 

Operative versus nonoperative

 

Mittal et al BMJ Open 2017

- operative v nonoperative management isolated Weber B with no talar shift

- RCT of 160 patients

- no difference in functional outcome

 

Tian et al J Orthop Surg Res 2024

- systematic review

- operative v non operative management isolated Weber B

- better outcomes with non operative management

 

Cast versus removable brace

 

Spierings et al Eur J Trauma Emerg Surg 2023

- systematic review of removable brace versus cast

- stable Weber B fibular fractures

- better outcomes and reduced complications with removable brace

 

Weight bearing

 

Stassen et al Eur J Orthop Trauma Surg 2024

- RCT of early weight bearing in brace versus NWB in cast

- improved early functional outcome with weight bearing

- in 16%, early weight bearing associated with lateral talar shift needing surgery

 

Unstable Weber B / torn deltoid ligament

 

Bimalleolar equivalent

 

Weber BWeber B

 

Management

 

ORIF fibular

- ensure medial joint space fully reduced

- may need to open medial joint / removed osteochondral fragments / deltoid ligament

 

Ankle Fracture Fibula ORIF Increased Medial Clear Space

Open medial joint line after reduction

 

ORIF options

 

Plate - 1/3 tubular / DCP / anatomic locking plate

Fibular nail

 

ORIF

 

Dhillon et al Eur J Orthop Traumatol Surg 2024

- systematic review of 18 studies and 4000 patients

- no difference in outcome between locking and non locking plates

 

Plate versus nail

 

Weber BFibular nail

 

Attia et al Foot Ankle Surg 2022

- meta-analysis of plate versus nail for fibular fractures

- 4 comparative studies and 260 patients

- increased functional outcomes with nail

- complication rate: plate 29% nail 8%

- infection rate: plate 8% nail 0%

- re-operation rate: plate 8% nail 5%

 

Fibular nail

 

Arthrex fibular nailArthrex fibular nail

Arthrex fibular nail PDF

 

Acumed fibular nail

Acumed fibular nail PDF

 

Vumedi fibular nail video

 

Acumed fibular nail video

 

Deltoid ligament repair

 

Guo et al PLoS One 2021

- systematic review of deltoid ligament repair in ankle fracture

- 8 studies and 400 patients

- improved outcome and decreased medial clear space with deltoid repair

 

Isolated Weber C fracture

 

Weber CWeber C

Weber C fracture                  Weber C fracture with deltoid ligament injury

 

MaisonneuveMaisonneuve

Maisonneuve injury: proximal fibula with open medial clear space

 

Definition

 

Fracture above syndesmosis

Syndesmosis disrupted +/- deltoid ligament

 

Syndesmotic injury

 

Xray assessment

 Increased tibio-fibular Clear space  Overlap Increased medial clear space

Medial border of the fibula

Lateral border of the posterior tibia (incisura fibularis)

Measured 1 cm above the plafond

Overlap of the fibula and the anterior tibial tubercle Deltoid ligament injury
<5mm AP and mortise

> 6 mm AP view

> 1 mm mortise view

Maisonneuve / proximal fibular injury
Ankle AP Xray Syndesmotic Measurements Ankle Mortice Xray Syndesmotic Measurements Maisonnerve

Intraoperative tests

 

Cotton test - clamp on fibular, apply lateral stress

Stress test - external rotation of foot

 

Management

 

ORIF fibular

Syndesmosis reduction and stabilization with plate versus screws

 

Reduction syndesmosis

 

Avoid malreduction

- arthroscopic visualization

- open reduction of syndesmosis via anterolateral approach

 

Vumedi open reduction syndesmosis

 

Foot in neutral

- clamp across medial and lateral malleolus

- don't reduce in plantarflexion as posterior talus is more narrow

- don't over reduce the joint

- check symmetrical joint space on mortise view

 

ORIF Options

 

Screw fixation

Suture button

 

Xu et al J Foot Ankle Surg 2021

- meta-analysis of 12 studies and 600 patients

- suture button had improved functional outcomes at 2 years

- suture button had reduced malreduction

- suture button had reduced implant failure / removal / irritation

 

Screw fixation

 

Technique

 

AO surgery reference surgical technique

 

Technique

- level of syndesmosis (1.5 - 3 cm from joint)

- angle 30 degrees anterior

 

One versus Two screws

 

Hoiness et al J Orthop Trauma 2004

- single 4.5 mm 4 cortical screw versus two 3.5 mm 3 cortices screw

- RCT of 64 patients

- improved function and less pain at 3 months with tricortical

- no difference at 1 year

 

3.5 mm versus 4.5 mm screws

 

Stuart et al Foot Ankle Int 2011

- retrospective study of 137 patients

- 3.5 mm screws more likely to break than 4.5 mm screws

- no difference in outcome

 

3 versus 4 cortices

 

Moore et al Foot Ankle Int 2006

- RCT of 127 patients

- 2 x 3.5 mm screws, 3 versus 4 cortices

- no loss of reduction with 4 cortices

- 3 loss of reduction with 3 cortices, all who began early weight bearing against guidance



Bioabsorbable versus metallic screws

 

van der Eng et al J Foot Ankle Surg 2015

- systematic review of bioabsorbable versus metallic screws

- complication rate bioabsorbable: 23%

- complication rate metallic screws: 6%

 

Screw removal

 

broken screwsBroken screws

 

Sanders et al Bone Joint J 2021

- 150 patients RCT of routine screw removal versus on demand screw removal

- no functional difference at 1 year (or 4 years in later follow up study)

- increased complications with routine screw removal

 

Acevedo et al J Orthop 2024

- systematic review of 3 RCT of routine screw removal versus on demand screw removal

- no difference functional outcome at 1 year

- routine screw removal associated with increased complication

 

Suture button

 

Technique

 

Arthrex tightrope technique PDF

 

Arthrex surgical technique video

 

One or two suture buttons

- 1.5 - 3 cm above joint line

- angle 30 degrees anterior

- need to ensure entry point centered on fibula

- risk of saphenous nerve damage of medial side

- consider medial incision to identify and protect nerve

- talus at neutral dorsiflexion when tightening

 

One versus two buttons



Kurtoglu et al Medicine 2021

- one versus two suture buttons in 40 patients

- no difference in outcome

- two suture buttons more costly

 

Deltoid ligament repair

 

Wang et al J Foot Ankle Surgery 2021

- systematic review of deltoid ligament repair in ankle sysdesmotic injury

- 9 studies and 500 patients

- no difference in pain or functional outcome

- lower malreduction with deltoid ligament repair