What are the indications for fixation in a fibula (fibular) fracture?

Indications for Fibula Fracture Fixation

Fibula fractures require fixation when they are part of an unstable ankle fracture pattern, when associated with distal tibial shaft fractures at the same level requiring bridging plate fixation, or when fibular stabilization is needed to aid tibial reduction or provide additional stability in pilon fractures.

Ankle Fractures with Fibular Involvement

Unstable Ankle Fractures

• Fixation is indicated for displaced unstable ankle fractures where the fibula is part of a bi- or trimalleolar fracture pattern, or when there is increased medial clear space (>4mm), indicating instability 1.
• Open reduction and internal fixation remains the standard treatment for displaced unstable ankle fractures involving the fibula 2, 3.
• Weight-bearing radiographs help determine stability, which is the most important criterion in treatment decisions for malleolar fractures 1.

High-Risk Features Requiring Fixation

Fixation should be strongly considered when any of the following are present 1:

• Medial tenderness, bruising, or swelling
• Fibular fracture above the syndesmosis
• Bi- or trimalleolar fractures
• Open fracture
• High-energy fracture injury

Distal Tibial Shaft Fractures (AO 42 Fractures)

Critical Decision Point: Fracture Level Alignment

• Fibular fixation is recommended when the tibial and fibular fractures are at the same level AND the tibia is stabilized with a bridging plate 4.
• This specific scenario shows significantly higher non-union rates when the fibula is left unfixed 4.
• When fractures are not at the same level, fibular fixation may be omitted without increased risk of non-union 4.

Fixation Device Considerations

• The type of tibial fixation device (nail versus plate) influences the decision, with bridging plates creating greater need for fibular stabilization 4.

Tibial Pilon Fractures

Selective Fixation Approach

• Fibular fixation is NOT routinely necessary in pilon fractures if primary stability can be achieved with tibial fixation alone 5.
• Reserve fibular fixation for cases where it aids in tibial reduction or provides additional stability 5.
• No significant differences in mechanical complications (malunion, delayed union, nonunion, implant failure) occur between fixed and unfixed fibulas in pilon fractures 5.

Important Caveat

• Patients without fibular fixation may have higher wound complication rates (44% vs 25.9%), though this difference was not statistically significant 5.

Timing Considerations for Severe Trauma

Hemodynamically Stable Patients

• Early definitive fixation within 24 hours is recommended when there is no severe visceral injury, circulatory shock, or respiratory failure 1.
• This approach reduces local and systemic complications 1.

Hemodynamically Unstable Patients

• Delayed definitive fixation with initial temporary stabilization is recommended when severe visceral injuries, circulatory shock, or respiratory failure are present 1.
• Use damage control orthopedic surgery principles with external fixation or traction initially 1.
• Proceed with definitive fixation once clinical status stabilizes 1.

Surgical Technique Options

Intramedullary Fixation

• Intramedullary nail or screw fixation represents a viable alternative to plate fixation with less soft tissue disruption 2, 3.
• Shows low wound complication rates (0.6%), high anatomic reduction rates (93.3%), and low loss of reduction (1.1%) 3.
• All patients in one series achieved fracture union with minimal secondary procedures 2.

Plate Fixation

• Traditional plate fixation remains the most frequently used method with favorable outcomes 2.
• Double plating with two one-third tubular plates can be considered for problem fractures requiring enhanced fixation 6.

Key Clinical Pitfalls

• Do not assume all fibula fractures need fixation—assess stability, fracture pattern, and associated injuries first 5, 4.
• Avoid missing vascular injury—perform CT angiography if ankle-brachial index <0.9, isolated neurological deficit, or proximity to major vessels 1.
• Do not delay fixation unnecessarily in stable patients—early fixation within 24 hours reduces complications 1.
• Consider soft tissue condition—existing swelling requires careful attention to soft tissue handling and may influence timing 7.