Management of Proximal Fibula Head Fractures
Proximal fibula head fractures should be treated with open reduction and internal fixation using cannulated screws or suture anchors, with early range of motion to optimize functional outcomes and prevent complications. 1, 2
Initial Assessment and Management
Pain control and immobilization:
- Implement a formalized analgesia protocol including regular paracetamol and cautious opioid use
- Consider femoral or fascia iliaca nerve blocks for additional pain control
- Immobilize the affected limb temporarily until definitive treatment
Diagnostic evaluation:
- Obtain plain radiographs as the initial diagnostic tool
- Consider MRI if associated ligamentous injury is suspected, particularly of the posterolateral corner (PLC)
- Assess for concomitant injuries, especially posterolateral corner injuries which are commonly associated with fibular head avulsion fractures
Surgical Management
Indications for Surgery
- Displaced fibular head fractures
- Fractures associated with posterolateral corner injuries
- Fractures causing instability of the proximal tibiofibular joint
Surgical Techniques
Cannulated screw fixation 1:
- Provides robust fixation across multiple cortices
- Allows for early range of motion
- Demonstrated excellent outcomes with 100% union rate in a study of 37 patients
Suture anchor fixation 2:
- Effective technique for avulsion fractures
- Particularly useful when associated with posterolateral corner injuries
- Allows for anatomic restoration of ligamentous attachments
Tension-slide technique 3:
- Novel approach for comminuted fibular head fractures
- Particularly indicated when there is posterolateral knee instability
- Goals include reconstitution of posterolateral stability and restoration of anatomic relationships
Surgical Approach
- Lateral approach with careful identification and protection of the peroneal nerve
- Anatomical reduction of the fracture fragments
- Secure fixation to allow early mobilization
- Consider transfixation to the tibia with a positioning screw in cases with associated proximal tibiofibular joint dislocation 4
Postoperative Management
- Begin early range of motion exercises to prevent stiffness
- Progressive weight-bearing as tolerated based on fracture stability
- Monitor for complications including:
- Peroneal nerve injury
- Nonunion
- Chronic instability of the proximal tibiofibular joint
- Posterolateral knee instability
Follow-up Care
- Regular clinical and radiographic follow-up to assess fracture healing
- Evaluate range of motion and knee stability
- Assess for potential complications such as:
- Chronic pain
- Instability of the proximal tibiofibular joint
- Peroneal nerve dysfunction
Special Considerations
- In cases with associated tibial shaft fractures, address both injuries with appropriate fixation 4
- Be cautious with proximal fibula osteotomy in patients with rheumatoid arthritis, as this may lead to stress fractures of the proximal tibia 5
- For comminuted fractures with posterolateral instability, prioritize restoration of both bony and ligamentous stability 3
Outcomes
Based on recent research, proper surgical management of fibular head fractures yields excellent outcomes: