The interosseus membrane is the stout connection between the tibia . The injury is common in athlete who is engaged in collision or contact sport . 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. Incision. Are you sure you want to trigger topic in your Anconeus AI algorithm? Summary. C3: proximal fracture of the fibula. The fibula is a site of five muscles attachment. Diagnosis is made with plain radiographs of the ankle. Diagnosis is made with plain radiographs of the ankle. Repeated cleanings prior to closing the wound may be used instead. Wang Q, Whittle M, Cunningham J, et al. At its most proximal part, it is at the knee just posterior to the proximal tibia, running distally on the lateral side of the leg where it . Fractures may involve the knee, tibiofibular syndesmosis, tibia, or ankle joint. 2023 Lineage Medical, Inc. All rights reserved. Fibula fractures occur around the ankle, knee, and middle of the leg. Usually, it gets worse with activity and better with rest. Fractures of the tibia and fibula are typically diagnosed through physical examination andX-rays of the lower extremities. Lateral short oblique fibula fracture (anteroinferior to posterosuperior), 3. Fibula Fracture: Types, Treatment, Recovery, and More - Healthline Tibia and fibula are the two long bones located in the lower leg. C2: diaphyseal fracture of the fibula, complex. Copyright 2023 Lineage Medical, Inc. All rights reserved. Numbness or paresthesias may arise if damage to the peroneal nerve has occurred. In 1 recent study, shin guards did not seem to prevent tibia and fibula fractures in soccer players (14). Fibula fractures - UpToDate Posterolateral corner (PLC) injuries are traumatic knee injuries that are associated with lateral knee instability and usually present with a concomitant cruciate ligament injury (PCL > ACL). compared to IM nailing of tibia fractures: increased risk of wound complications and hardware irritation, similar rates of union in closed fractures, greater radiation exposure intraoperatively, risk of damage to the superficial peroneal nerve during percutaneous screw insertion, holes 11,12, and 13 (proximally) of a 13 hole plate place nerve at risk, prior studies have demonstrated some use in, outcomes (controversial, as recent studies have not fully supported these findings), decrease need for subsequent autologous bone-grafting, decrease need for secondary invasive procedures, no current scoring system to determine if an amputation should be performed, relative indications for amputation include, most important predictor of eventual amputation is the severity of ipsilateral extremity, most important predictor of infection other than early antibiotic administration is transfer to definitive trauma center, study shows no significant difference in functional outcomes between amputation and salvage, loss of plantar sensation is not an absolute indication for amputation, functional (patellar tendon bearing) brace at around 4 weeks, close follow-up with repeat radiographs to ensure no displacement, can wedge cast to correct slight deformity, within 24 hours of initial injury to decrease risk of infection, sharp debridement of nonviable soft tissue & bone, thorough irrigation of contaminated wound, immediate closure of open wounds is acceptable if minimal contamination is present and is performed without excessive skin tension. Weber C fractures can be further subclassified as 6. High-energy fractures, such as those caused by serious car accidents or major falls, are more common in older children. Posterolateral corner (PLC) injuries are traumatic knee injuries that are associated with lateral knee instability and usually present with a concomitant cruciate ligament injury (PCL > ACL). Generally, fibula fractures do well, and most patients have normal function at long-term follow-up (. Diagnosis is confirmed by plain radiographs of the tibia and adjacent joints. The treatment of an open tibial fracture starts with antibiotics and a tetanus shot to address the risk of infection. It is the main weight-bearing bone of the two. Are you sure you want to trigger topic in your Anconeus AI algorithm? Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. Epidemiology of fractures in England and Wales. A CT scan may be required to further characterize the fracture pattern and for surgical planning. Are you sure you want to trigger topic in your Anconeus AI algorithm? Weber C Fractures : Wheeless' Textbook of Orthopaedics Description. Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. All Rights Reserved. Etiology. These fractures occur in the knee end of the tibia and are also called tibial plateau fractures. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. Splints and Casts: Indications and Methods | AAFP ORIF of fibula fractures; resection of fibula; excision of fibula bone lesions; Internervous plane: Between . Tibia and fibula fractures can be treated with standard bone fracture treatment procedures. Mechanism of Injury [edit | edit source]. 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. Nielson JH, Sallis JG, Potter HG, et al. The fibular shaft is an origin for multiple muscles of the leg, including musclesof the anterior compartment (extensor digitorum longus, extensor hallucis longus, peroneus tertius), the lateral compartment (peroneus longus, peroneus brevis), the superficial posterior compartment (soleus), and the deep posterior compartment (tibialis posterior and flexor hallucis longus). Login. Ulnar gutter splint/cast. - comminuted fractures of the fibula are often high energy injures resulting from direct lateral trauma or vertical loading; - comminution alters landmarks & complicates rotation and length assessment; Located posterolaterally to the tibia, it is much smaller and thinner. 2023 - TeachMe Orthopedics. Maisonneuve fractures with syndesmotic injury imply injury to the medial side of the ankle joint. Patients are counseled that, although fibula fractures. 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. The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. posterior border of the biceps femoris tendon, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, may be done supine with bump under affected limb or in lateral position, Make linear longitudinal incision along the, may extend proximally to a point 5cm proximal to the fibular head, begin proximally and incise the fascia taking great care not to damage the common peroneal nerve, about 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia, distal - may be extended distally to become continuous with, Kocher lateral approach to the ankle and tarsus, susceptible to injury at junction of middle and distal third of leg, if injured will cause numbness on the dorsum of the foot. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. Sproule JA, Khalid M, OSullivan M, et al. Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required. They account for 10 to 15 percent of all pediatric fractures. This article focuses on the shaft of the fibula, which can be located between the neck of the fibula, the narrowed portion just distal to the fibular head, and the lateral malleolus, which in concert with the posterior and medial malleoli, form the ankle joint. Or an external fixator may be used to surgically repair the wound. Fibula Stress Fracture - Symptoms, Causes, Treatment & Rehabilitation This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint, 4. 2023 Lineage Medical, Inc. All rights reserved, posterior border of the biceps femoris tendon, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, may be done supine with bump under affected limb or in lateral position, Make linear longitudinal incision along the, may extend proximally to a point 5cm proximal to the fibular head, begin proximally and incise the fascia taking great care not to damage the common peroneal nerve, about 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia, distal - may be extended distally to become continuous with, Kocher lateral approach to the ankle and tarsus, susceptible to injury at junction of middle and distal third of leg, if injured will cause numbness on the dorsum of the foot. Patients with tibia fractures, syndesmosis injuries, or ankle fractures should be referred to an orthopaedic surgeon. They are also called tibial plafond fractures. The superficial peroneal nerve innervates the musculature of the lateral compartment and is responsible for eversion and, to a much milder degree, plantarflexion of the foot. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. muscles of the posterior compartment ( tibial nerve) Approach. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I: Preparation. low energy (fall from standing, twisting, etc) result of indirect, torsional injury. "use strict";var wprRemoveCPCSS=function wprRemoveCPCSS(){var elem;document.querySelector('link[data-rocket-async="style"][rel="preload"]')?setTimeout(wprRemoveCPCSS,200):(elem=document.getElementById("rocket-critical-css"))&&"remove"in elem&&elem.remove()};window.addEventListener?window.addEventListener("load",wprRemoveCPCSS):window.attachEvent&&window.attachEvent("onload",wprRemoveCPCSS); BONE DYSPLASIAS, METABOLIC BONE DISEASES, AND GENERALIZED SYNDROMES, THE ORTHOPAEDIC MANAGEMENT OF MYELODYSPLASIA AND SPINA BIFIDA, The Diagnosis and Management of Musculoskeletal Trauma, Surgical Reconstruction of the Lateral Collateral Ligament, Staying Out of Trouble with the Hip: Fibular Fracture - Physiopedia Distal tibial physeal fractures in children that may require open reduction. Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury ( distal tibiofibular syndesmosis , deltoid ligament) and/or fracture of the medial malleolus. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Posterolateral Corner Injury, Question SessionPosterolateral Corner Injury. Pronation - External Rotation (PER) 1. paralyzed), or those unfit for surgery, angulation and rotational alignment are well maintained with casting, however, shortening is hard to control, risk of shortening higher with oblique and comminuted fracture patterns, risk of varus malunion with midshaft tibia fractures and an intact fibula, high success rate if acceptable alignment maintained, non-union occurs in approximately 1% of patients treated with closed reduction, all open tibia fractures require an emergent I&D, surgical debridement within 12-24 hours of injury, wounds should be irrigated and dressed with saline-soaked gauze in the emergency department before splinting, all open tibia fractures require immediate antibiotics, should be administered within 3 hours of injury, standard abx for open fractures (institution dependent), cephalosporin given continuously for 24 hours, after definitive surgery in Grade I, II, and IIIA open fractures, aminoglycoside added in Grade IIIB injuries, tetanus vaccination status should be confirmed and appropriate prophylaxis should be administered if necessary, early antibiotic administration is the most important factor in reducing infection, emergent and thorough surgical debridement is also an, must remove all devitalized tissue including cortical bone, open fractures with soft tissue defects/contamination, uniplanar, circular, hybrid external fixators all available, should be converted to intramedullary nail within 7-21 days, ideally less than 7 days, longer time to union and worse functional outcomes, high rate of pin tract infections; avoid intra-articular placement given risk for septic arthritis, unacceptable alignment with closed reduction and casting, soft tissue injury that will not tolerate casting, ipsilateral limb injury (i.e., floating knee), reamed nailing allows for larger diameter nail, provisional reduction techniques (blocking screws, plating, etc), particularly useful for proximal 1/3 tibial shaft fractures, for closed tibia fractures treated with nailing, risks for nonunion: gapping at fracture site, open fracture and transverse fracture pattern, shorter immobilization time, earlier time to weight-bearing, and decreased time to union compared to casting, decreased malalignment compared to external fixation, improved fracture alignment with suprapatellar nailing, reamed may have higher union rates and lower time to union than unreamed nails in closed fractures (controversial), reamed nails are safe for use with open fractures, with no evidence of decreased nonunion rates in open fractures, recent studies show no adverse effects of reaming (infection, embolism, nonunion), reaming with the use of a tourniquet is not associated with thermal necrosis of the tibial shaft, despite prior studies suggesting otherwise, higher rate of locking screw breakage with unreamed nailing, proximal tibia fractures with inadequate proximal fixation from IM nailing, distal tibia fractures with inadequate distal fixation from IM nail, tibia fractures in the setting of adjacent implant/hardware (i.e. (0/3), Level 2 Open fractures of the tibia are common among children and adults. Weber classification of ankle fractures - Radiopaedia The deep peroneal nerve innervates the musculature of the anterior compartment and is responsible for the dorsiflexion of the foot and toes. Fibula bone fracture is a common injury seen in the emergency room. A lateral malleolus fracture is a fracture of the lower end of the fibula. Fibula Fracture: Types, Symptoms, and Treatment - Verywell Health 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. It's possible to fracture the fibula by placing too much pressure on it over and over again. 5.0 (1) Login. 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 Posterolateral Corner Injury. Outcome after surgery for Maisonneuve fracture of the fibula. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. These fractures are usually transverse (across) or oblique (slanted) breaks in the bone. Diagnosis is made with plain radiographs of the ankle. Ulnar side of hand. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. There will be a pain in the lower leg on weight-bearing although . - C1 diaphyseal fracture of the fibula, simple. Depending on the exact location, a proximal tibial fracture may affect the stability of the knee as well as the growth plate. Then the injury is cleaned to remove any debris and bone fragments. (0/3), Level 1 Q: Do syndesmotic screws require removal? Transverse comminuted fracture of the fibula above the level of the syndesmosis. Are you sure you want to trigger topic in your Anconeus AI algorithm? Type of screw fixation for repairing the syndesmosis: Differences have not been found between syndesmotic screws that engage 3 or 4 cortices (, 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 (. Nonsurgical Treatment. Patients with fractures of the distal fibula and ankle instability are nonweightbearing until the fracture heals. Treatment may be nonoperative or operative depending on . A common result of damage to the deep peroneal nerve is drop foot, in which there is a loss of the capacity to dorsiflex the foot. Distal tibial metaphyseal fractures usually heal well after setting them without surgery and applying a cast. The diagnosis is made by x-raying the ankle. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. 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. Surgery may also be needed depending on the wound size, amount of tissue damage and any vascular (circulation) problems. a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint. (2/3), Level 4 if skin cannot be closed, vac-assisted closure should be considered in short-term. Full healing usually is accomplished by 68 weeks. Patients with isolated fibular shaft fractures are instructed to bear partial weight. seen with SER-type fracture patterns, AITFL avulsion of anterior tibial margin (tibial Sometimes they may also involve the fracture of the growth plate (physis) located at each end of the tibia. B2 w/ medial lesion (malleolus or ligament) B3 w/ a medial lesion and fracture of posterolateral tibia. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. 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.
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