What is the management approach for a proximal fibular head fracture?

Management of Proximal Fibular Head Fractures

Conservative management with protected weight-bearing and early range of motion exercises is the recommended first-line treatment for most isolated proximal fibular head fractures, with surgical intervention reserved for displaced fractures or those with associated ligamentous injuries. 1

Assessment and Classification

When evaluating proximal fibular head fractures, consider:

• Mechanism of injury (direct trauma, avulsion injury, associated knee trauma)
• Displacement of fracture fragments
• Associated injuries (posterolateral corner injuries, lateral collateral ligament avulsion)
• Stability of the proximal tibiofibular joint
• Patient's functional demands and activity level

Treatment Algorithm

Conservative Management (First-Line for Most Cases)

• Indicated for:

  • Non-displaced or minimally displaced fractures
  • Stable proximal tibiofibular joint
  • Absence of significant ligamentous injuries

• Protocol:

  • Short period of immobilization (1-2 weeks) with knee brace
  • Protected weight-bearing with crutches for 4-6 weeks
  • Early range of motion exercises to prevent stiffness
  • Gradual return to activities as pain allows
  • Regular radiographic follow-up to ensure proper healing

Surgical Management

• Indicated for:

  • Displaced fractures (>2-3mm)
  • Unstable proximal tibiofibular joint
  • Associated posterolateral corner injuries
  • Avulsion fractures with ligamentous instability
  • Failed conservative management

• Surgical Options:

  1. Cannulated screw fixation: Provides robust fixation across multiple cortices and allows for early motion 1
  2. Suture anchor fixation: Effective technique for avulsion fractures associated with posterolateral corner injuries 2
  3. Temporary screw fixation: For proximal tibiofibular joint instability (removed after 3-6 months) 3

Special Considerations

Associated Injuries

Approximately one-third of tibial plateau fractures are associated with proximal fibula fractures 4. When fibular head fractures occur with other injuries:

• Evaluate for posterolateral corner injuries (especially lateral collateral ligament avulsions)
• Assess stability of the proximal tibiofibular joint
• Consider MRI to evaluate soft tissue injuries

Rehabilitation Protocol

1. Early Phase (0-2 weeks):

   • Immobilization as needed for pain control
   • Protected weight-bearing with assistive devices
   • Gentle range of motion exercises

2. Intermediate Phase (2-6 weeks):

   • Progressive weight-bearing as tolerated
   • Increased range of motion exercises
   • Strengthening exercises for surrounding musculature

3. Late Phase (6+ weeks):

   • Full weight-bearing
   • Sport-specific or activity-specific rehabilitation
   • Return to pre-injury activities when clinically appropriate

Potential Complications

• Peroneal nerve injury (due to proximity to fibular head)
• Proximal tibiofibular joint instability
• Delayed union or nonunion
• Post-traumatic arthritis
• Knee instability (if associated ligamentous injuries)

Follow-up Recommendations

• Regular radiographic assessment at 2,6, and 12 weeks
• Clinical evaluation of knee stability and range of motion
• Assessment of peroneal nerve function
• Monitoring for return to functional activities

The management of proximal fibular head fractures should focus on restoring stability while allowing for early mobilization to prevent stiffness. While most isolated fractures can be managed conservatively with excellent outcomes, surgical intervention provides good results when indicated for displaced fractures or those with associated injuries.