What to do if a patient's fibula is broken again with a rod placed 3 months ago, should they be sent to the Emergency Room (ER)?

Re-fracture of Fibula with Intramedullary Rod in Place: Emergency Department Referral Required

Yes, send this patient to the Emergency Department immediately. A re-fracture of the fibula only 3 months after intramedullary rod placement represents a significant mechanical failure requiring urgent orthopedic evaluation, imaging, and likely surgical revision 1.

Why Immediate ER Transfer is Necessary

Hardware Failure and Vascular Risk

• The American Heart Association recommends immediate ER transfer for patients with vascular compromise, severe bleeding, or inability to maintain adequate immobilization 1
• A re-fracture with hardware in place suggests either:
  • Inadequate initial fixation or healing
  • Hardware failure or loosening
  • New high-energy trauma requiring assessment for associated injuries 1

Time-Sensitive Surgical Planning

• Delays in diagnosis and treatment are associated with increased complications, length of hospital stay, and mortality in fracture patients 2
• The patient requires immediate orthogonal radiographic views (AP and lateral) to assess the fracture pattern, hardware position, and any displacement 2
• Office settings lack the capability for immediate radiographic evaluation, IV access, continuous monitoring, and rapid surgical consultation that this patient requires 2

Critical Assessment Needs

The ER provides essential capabilities that cannot be replicated in an office setting:

• Immediate orthogonal radiographic views to evaluate fracture displacement and hardware integrity 2
• Assessment for neurovascular compromise (distal pulses, perfusion, sensation) 1
• Evaluation for compartment syndrome, which can develop with re-fracture 3
• Coordination with orthopedic surgery for potential urgent operative intervention 2

What the ER Will Provide

Immediate Diagnostic Workup

• Standard radiographic evaluation with AP and lateral views of the entire fibula, including the hardware 2
• Assessment of the tibial plateau fracture site for any progression or new injury 1
• Neurovascular examination documentation 1

Pain Management and Stabilization

• Formalized analgesia protocols including IV opioids if needed for acute pain control 2
• Adequate immobilization to prevent further displacement 1
• The existing RLE immobilizer may be insufficient for a new fracture with hardware in place 1

Surgical Consultation

• Orthopedic surgery consultation for potential hardware removal, revision fixation, or exchange nailing 4, 5
• Approximately 47-53% of combined tibial plateau-fibula fractures require surgical intervention, and this percentage is likely higher with hardware failure 1

Common Pitfalls to Avoid

Do Not Attempt Office-Based Management

• The American College of Cardiology warns against under-triaging unstable fractures that require ER evaluation 1
• Office radiographs are insufficient for evaluating hardware integrity and fracture displacement 2
• Delayed diagnosis can lead to malunion, nonunion, or compartment syndrome 6

Do Not Assume Stability Based on Hardware Presence

• The presence of an intramedullary rod does not guarantee stability with a new fracture 5
• Periprosthetic fractures adjacent to hardware often require early surgical intervention, particularly in active patients 5
• Nonoperative management of fractures adjacent to hardware may lead to delayed union 5

Document Neurovascular Status Before Transfer

• Ensure documentation of distal pulses, capillary refill, sensation, and motor function 1
• Any neurovascular compromise elevates this to an absolute emergency requiring immediate transfer 1

Transfer Instructions

Provide the patient with:

• Strict non-weight bearing instructions 3
• Adequate immobilization of the entire lower extremity 1
• Pain medication for transport if available 2
• Clear documentation of the mechanism of re-injury, neurovascular status, and previous surgical history 2

The ER will coordinate with orthopedic surgery for definitive management, which may include hardware removal, exchange nailing, or revision fixation depending on the fracture pattern and healing status of the original injury 4, 5.