What is the step-by-step procedure for treating a fibula fracture with plating?

Surgical Technique for Fibula Fracture Plating

For displaced fibula fractures requiring surgical fixation, open reduction and internal fixation (ORIF) with plate osteosynthesis achieves a 99.5% union rate and should be performed using either posterior antiglide plating for Weber B fractures or lateral plating for other fracture patterns, with timing dependent on soft tissue condition. 1, 2

Preoperative Assessment and Planning

Indications for Surgical Fixation

• Surgical fixation is indicated when radiographic parameters show radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 1
• Associated syndesmotic injuries require surgical fixation 1
• Displaced Weber B fractures benefit from posterior plating technique 3
• Fracture stability assessment requires evaluation of medial clear space (<4 mm confirms stability) 4, 5

Imaging Requirements

• Obtain standard three-view radiographs: anteroposterior, lateral, and mortaja views to evaluate fracture stability 5
• Weight-bearing radiographs provide critical information for fractures of uncertain stability 4

Timing of Surgery

Staged Protocol for Complex Fractures

• For complex pilon fractures with associated fibula fractures and significant soft tissue swelling, perform immediate (within 24 hours) fibular ORIF followed by delayed definitive reconstruction 6
• Initial fibular fixation restores length and provides provisional stability 6
• Delay formal open reconstruction until soft tissue swelling subsides (average 12.7 days for closed fractures, 14 days for open fractures) 6
• This staged approach reduces wound complications from 30-50% (historical rates) to <20% 6

Immediate Fixation Considerations

• Simple, isolated fibula fractures without significant soft tissue compromise can undergo immediate ORIF 2
• Open fractures require immediate debridement and provisional stabilization 6

Surgical Technique: Step-by-Step

Patient Positioning and Preparation

• Position patient supine on radiolucent table
• Apply tourniquet to thigh (optional, based on surgeon preference)
• Prepare and drape entire lower leg circumferentially to allow manipulation

Incision and Approach

For Lateral Plating:

• Make longitudinal incision centered over lateral fibula, typically 8-12 cm in length 7
• Incision should be positioned between lateral malleolus and fibular shaft
• Identify and protect superficial peroneal nerve branches
• Develop plane between peroneal tendons (anteriorly) and sural nerve (posteriorly)

For Posterior Plating (Weber B fractures):

• Make posterolateral incision along posterior border of fibula 3
• Identify interval between peroneal tendons and flexor hallucis longus
• Retract peroneal tendons anteriorly to expose posterior fibular surface 3

Fracture Reduction

• Remove periosteum and soft tissue from fracture site to visualize bony anatomy 4
• Achieve anatomic reduction using:
  • Direct visualization of fracture lines
  • Reduction clamps to hold fragments
  • Temporary K-wires for provisional fixation
• Verify reduction with intraoperative fluoroscopy in AP, lateral, and mortise views
• Ensure restoration of fibular length, rotation, and alignment (critical for ankle mortise stability)

Plate Selection and Application

Plate Type:

• One-third tubular plate (most common, used in 56% of cases) 3
• 3.5 mm dynamic compression plate for larger patients or comminuted fractures 6
• Locking plates for osteoporotic bone (5.9% of cases) 2
• Six-hole plate provides optimal fixation (used in 56% of cases) 3

Plate Positioning:

For Lateral Plating:

• Apply plate to lateral surface of fibula
• Contour plate to match fibular anatomy
• Position plate to allow minimum 3 screws proximal and distal to fracture 2

For Posterior Plating (Antiglide Technique):

• Apply unbent one-third tubular plate to posterior fibular surface 3
• Plate acts as buttress preventing proximal migration of distal fragment
• This technique eliminates risk of intraarticular or palpable screws and provides superior distal fixation 3

Screw Fixation

• Drill and measure for appropriate screw length to avoid intraarticular penetration 3
• Place lag screw through plate across fracture line for interfragmentary compression (used in 72% of cases) 3
• Insert remaining cortical screws in neutral mode:
  • Minimum 3 screws proximal to fracture
  • Minimum 3 screws distal to fracture
  • Achieve bicortical purchase when possible 2
• Verify screw position with fluoroscopy to ensure no intraarticular penetration

Bone Grafting (If Needed)

• For comminuted fractures or bone defects, prepare perforations in native bone to improve blood supply 4
• Apply autogenous bone graft from iliac crest or local metaphyseal bone 4
• Pack graft into defects to provide structural support

Wound Closure

• Irrigate wound copiously with normal saline
• Achieve tension-free closure with layered technique 4
• Close deep fascia with absorbable sutures
• Close skin with monofilament non-absorbable sutures using interrupted or vertical mattress technique 4
• Apply sterile dressing and well-padded splint

Special Considerations

Combined Tibia-Fibula Fractures

• For distal third tibia-fibula fractures, one-incision double-plating technique reduces wound complications 7
• Single anterolateral incision allows access to both tibia and fibula
• Fix fibula first to restore length, then address tibial fracture 7
• This approach achieved 96% union rate (24/25 fractures) with only one delayed union 7

Syndesmotic Injury Management

• Failure to identify associated syndesmotic injuries leads to poor outcomes 1
• After fibular fixation, assess syndesmotic stability with external rotation stress
• If unstable, place syndesmotic screws (typically 1-2 screws, 3.5 or 4.5 mm) 1

External Fixation Alternative

• For severely comminuted fractures with poor soft tissue envelope, consider external fixation spanning ankle 8
• Routine plating of fibula with external fixation increases wound infection risk (5/22 cases, 23%) without improving outcomes 8
• External fixation alone for fibula achieves similar radiographic and clinical results 8

Postoperative Management

Immediate Care

• Maintain splint for 10-14 days until suture removal 4
• Elevate leg above heart level for first 48-72 hours
• Prescribe analgesics and monitor for compartment syndrome 1

Weight-Bearing Protocol

• For stable fixation of isolated fibula fractures, allow immediate weight-bearing as tolerated with removable boot 1, 5
• Use assistive devices (crutches, walker) initially for comfort 5
• Early weight-bearing prevents muscle atrophy and joint stiffness 5

Rehabilitation

• Begin active finger and toe motion exercises immediately after diagnosis 1
• Initiate formal physical therapy for range of motion and strengthening after immobilization period (typically 6 weeks) 1
• Progress to full activities as tolerated, typically 8-12 weeks

Radiographic Follow-up

• Obtain radiographs at 3 weeks to confirm maintained reduction 1
• Repeat imaging at time of immobilization removal (6 weeks) 1
• If displacement or instability develops, reevaluate weight-bearing status immediately 5

Complications and Management

Wound Complications

• Overall complication rate: 19.3% (mostly minor) 2
• Posterior plating eliminates wound complications seen with lateral approach (0% vs 23% infection rate) 3, 8
• Partial-thickness skin necrosis (17% in closed fractures): treat with local wound care and oral antibiotics 6
• Deep infection (1.7%): requires surgical debridement and intravenous antibiotics 2

Hardware-Related Issues

• Peroneal tendinitis (12.5% with lateral plating): typically resolves in 4-8 weeks 3
• Hardware removal required in 13.4% of cases for symptomatic implants 2
• Syndesmosis screw removal needed in 5.7% 2

Fracture Healing Problems

• Nonunion rate: 0.5% with plate fixation 2
• Delayed union: treat conservatively with continued protected weight-bearing 7
• Malunion risk increases without fibular fixation (19% angular malunion rate) 8

Critical Pitfalls to Avoid

• Inadequate reduction of unstable fractures leads to malunion, post-traumatic arthritis, and poor functional outcomes 1
• Operating through swollen, compromised soft tissues increases infection risk dramatically—delay surgery until swelling subsides 6
• Intraarticular screw penetration causes cartilage damage and arthritis—verify all screw lengths fluoroscopically 3
• Missing syndesmotic injury results in chronic instability and requires revision surgery 1
• Insufficient distal fixation (fewer than 3 screws) risks loss of reduction 3

Outcomes

• Union rate with plate osteosynthesis: 99.5% 2
• Patient satisfaction: 95% (20/21 patients) with posterior plating technique 3
• Return to full weight-bearing: average 11.6 months 2
• Staged protocol for complex fractures reduces major wound complications to 3.4% in closed fractures and 10.5% in open fractures 6