Treatment of Intra-Articular Fibular Head Fractures
Intra-articular fibular head fractures require surgical fixation with open reduction and internal fixation (ORIF), as these injuries typically involve avulsion of the lateral collateral ligament attachment and compromise knee joint stability.
Surgical Indications
Intra-articular fibular head fractures are inherently unstable injuries that warrant operative management for several key reasons:
- Joint surface involvement necessitates anatomic restoration to prevent post-traumatic arthritis and maintain proper knee mechanics 1
- Associated ligamentous injury is common, particularly involving the lateral collateral ligament (LCL) and posterolateral corner structures, which require concurrent repair 2
- Avulsion mechanism creates displacement that cannot be adequately reduced or maintained with conservative treatment alone 2
Surgical Technique Options
Primary Fixation Methods
Lag screw fixation is appropriate for fractures with three or fewer articular fragments, as this pattern demonstrates superior outcomes with internal fixation 1. The technique involves:
- Open reduction through a lateral approach to visualize the articular surface 1
- Anatomic reduction of the joint surface under direct visualization 1
- Fixation with cannulated screws or small fragment screws depending on fragment size 2
Suture anchor fixation is effective for avulsion fractures where the bone fragment is too small for screw fixation 2. This technique:
- Allows secure reattachment of the LCL to the fibular head 2
- Is particularly useful in complex posterolateral corner injuries 2
- Provides adequate stability for early rehabilitation 2
Tension band wiring can be considered for simple two-part fractures, though this is less commonly reported in the literature 2.
Contraindications to ORIF
Severe comminution (more than three articular fragments) is associated with unsatisfactory outcomes even with modern fixation techniques 1. In these cases:
- Consider fibular head excision if the fracture cannot be reconstructed 1
- Ensure LCL reconstruction is performed if excision is necessary 2
- Accept that functional outcomes may be compromised with highly comminuted patterns 1
Post-Operative Management
- Early mobilization should begin once soft tissue healing permits, typically within 2-3 weeks, to prevent stiffness 1
- Protected weight-bearing for 6-8 weeks until radiographic union is confirmed 2
- Physical therapy focusing on range of motion and progressive strengthening 1
Critical Pitfalls to Avoid
- Underestimating associated injuries: Always assess for posterolateral corner injury, common peroneal nerve injury, and proximal tibiofibular joint instability 2
- Attempting conservative management: Unlike other minimally displaced fractures, intra-articular fibular head fractures with LCL avulsion will not heal in acceptable alignment without surgical intervention 2
- Inadequate fixation of comminuted fractures: Recognize when the fracture pattern exceeds the capability of internal fixation and consider alternative strategies 1