What is the management approach for a fibula fracture?

Management of Fibula Fractures

The management of fibula fractures should be determined based on fracture location, displacement, stability, and associated injuries, with stable isolated fibula fractures typically managed non-operatively while unstable or displaced fractures may require surgical fixation.

Classification and Initial Assessment

• Fibula fractures are commonly classified based on the mechanism of injury and location, with supination-external rotation (SE) and pronation-abduction (PA) being the two basic types at the level of the syndesmosis 1
• Initial assessment should include radiographs or CT to identify the fracture pattern, displacement, and any associated injuries 2
• MRI may be indicated in cases where there is suspicion of soft tissue injury or when the diagnosis is unclear 2

Management Approach

Non-operative Management

• Stable, non-displaced isolated fibula fractures can typically be managed with cast immobilization 1
• Initial stages of SE-type fractures are appropriate for non-operative management with cast immobilization 1
• Non-operative management should include:
  • Appropriate pain management with regular analgesics 2
  • Early finger and hand motion to prevent edema and stiffness if the upper extremity is immobilized 2
  • Progressive mobilization as healing progresses 2

Surgical Management

• Advanced lesions with displacement, instability, or those involving the ankle joint typically require open reduction and internal fixation (ORIF) 1
• Plate osteosynthesis is the most common method of surgical stabilization for fibular fractures, with a high union rate of 99.5% 3
• Surgical indications include:
  • Displaced fractures affecting ankle stability
  • Fractures associated with syndesmotic injury
  • Fractures with significant deformity or malrotation 2

Special Considerations

Fibula Fractures with Syndesmotic Injury

• When syndesmotic injury is present, additional fixation may be required to stabilize the distal tibiofibular joint 4
• Care must be taken with suture button placement in the fibula, as eccentric placement (particularly in the anterior third) may contribute to stress reactions or fractures 4
• In elite athletes, early surgical intervention should be considered for periprosthetic fibula fractures adjacent to syndesmotic fixation, as nonoperative management may lead to delayed union 4

Fibula Fractures with Tibial Plafond Fractures

• In tibial plafond fractures treated with external fixation spanning the ankle, routine plating of the fibula is not always necessary 5
• Good clinical results may be obtained without fixing the fibula in these cases, and fibular fixation is associated with a significant rate of complications including wound infections and nonunions 5

Postoperative Care and Rehabilitation

• Appropriate postoperative care should include:
  • Adequate pain management 2
  • Early mobilization when appropriate 2
  • Regular wound assessment and care 2
  • Monitoring for complications such as infection, hardware-related symptoms, and delayed union 3

Complications and Hardware Removal

• Overall complication rate for fibular plate fixation is approximately 19.3%, with most complications (79.5%) being minor 3
• Major complications include deep infection, nonunion/malunion, and osteomyelitis, occurring in about 1.7% of cases 3
• Hardware removal may be necessary in some cases, with the most common indications being infection and osteomyelitis 6
• Risk factors for hardware removal include male gender and presence of comorbidities 6

Follow-up

• Regular follow-up with radiographic assessment is essential to monitor fracture healing 2
• Physical therapy and rehabilitation should be initiated as appropriate based on fracture stability and healing progress 2
• Return to activities should be guided by clinical and radiographic evidence of healing 4