In an ORIF of a spiral tibial fracture, should the fixation screws be placed through the fibula?

Fibular Fixation in Spiral Tibial Fractures

In ORIF of spiral tibial shaft fractures, fibular fixation is generally not necessary and should be avoided unless the fibula fracture is at the same level as the tibial fracture or additional stability is required for reduction. 1, 2

Decision Algorithm for Fibular Fixation

Fix the Fibula When:

• The tibial and fibular fractures are at the same horizontal level - This specific scenario shows higher nonunion rates when the fibula is left unfixed, particularly when the tibia is stabilized with a bridging plate 1
• The fibula fracture would aid in achieving or maintaining tibial reduction - Complex fractures where fibular length restoration helps tibial alignment 3, 2
• There is syndesmotic instability - Critical for ankle stability 2
• Highly comminuted pilon fractures are present - Though this applies to articular fractures, not shaft fractures 2

Do NOT Fix the Fibula When:

• Primary tibial stability is achieved with tibial fixation alone - The majority of spiral shaft fractures fall into this category 3
• The fractures are at different levels - No increased risk of complications without fibular fixation 1
• Using intramedullary nailing for the tibia - The nail provides sufficient stability 4
• Distal metaphyseal extra-articular fractures treated with locking plates - Fibular fixation is unnecessary in non-syndesmotic injuries 4

Evidence Supporting Selective Fixation

A study of 79 tibial pilon fractures with associated fibular fractures found no statistically significant differences in mechanical complications (malunion, delayed union, nonunion, or implant failure) between patients with and without fibular fixation. 3 While wound complications trended higher in the non-fixation group (44% vs 25.9%), this was not statistically significant. 3

The critical exception is when both fractures lie on the same plane and the tibia is fixed with a bridging plate - this specific combination showed higher nonunion rates without fibular fixation. 1 This finding comes from a study of 60 patients with distal tibial shaft fractures (42 AO classification), where fracture level alignment was the only parameter influencing nonunion development. 1

Biomechanical Considerations

Fibular fixation increases construct stability in specific uniplanar motions, but this increased rigidity may paradoxically increase nonunion rates by stress-shielding the tibial fracture site. 2 The benefit is highly dependent on:

• Tibial fracture pattern 2
• Tibial fixation strategy (plate vs nail) 2
• Fibular fixation method 2
• Loading pattern of the entire construct 2

Common Pitfalls to Avoid

• Do not routinely fix all fibular fractures - This adds surgical time, wound complications, and potential for nonunion without mechanical benefit in most cases 3, 4
• Do not assume fibular fixation always helps - The increased stability can be detrimental by preventing physiologic loading of the tibial fracture 2
• Do not ignore fracture level alignment - This is the single most important factor in deciding whether fibular fixation is needed 1