Fibula bone fracture is a common injury seen in the emergency room. At its most proximal part, it is at the knee just posterior to the proximal tibia, running distally on the lateral side of the leg where it becomes the lateral malleolus at the level of the ankle. posterior border of the biceps femoris tendon, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine, may be done supine with bump under affected limb or in lateral position, Make linear longitudinal incision along the, may extend proximally to a point 5cm proximal to the fibular head, begin proximally and incise the fascia taking great care not to damage the common peroneal nerve, about 10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve pierces the fascia, distal - may be extended distally to become continuous with, Kocher lateral approach to the ankle and tarsus, susceptible to injury at junction of middle and distal third of leg, if injured will cause numbness on the dorsum of the foot. Pain will usually have developed gradually over time, rather than at a specific point in time that the athlete can recognise as when the injury occurred. Diagnosis can be suspected with a knee effusion and a positive dial test but MRI studies are required for confirmation. Outcome after surgery for Maisonneuve fracture of the fibula. Damage to this nerve may result in deficits in those movements. Medial malleolus transverse fracture or disruption of deltoid ligament, A - infrasyndesmotic (generally not associated with ankle instability), avulsion fracture of posterior tibia resulting from tripping, AITFL avulsion off anterior fibular tubercle usually Patients with fibular shaft or head fractures generally present with tenderness and swelling in the area of injury. Tibia and fibula fractures are characterized as either low-energy or high-energy. Boden BP, Lohnes JH, Nunley JA, et al. Diagnosis is made with plain radiographs of the ankle. Obtain AP and lateral views of the knee to look for associated injury to the knee. Legg-Calv-Perthes, Slipped Capital Femoral Epiphysis, and Transient , Thoracic Spondylosis, Stenosis, and DISC Herniations, Musculoskeletal Tissues and the Musculoskeletal System, This website uses cookies to improve your experience. Both the posterior and medial malleolus arepart of the distal end of the tibia. Diaphyseal tibial fractures are the most common long bone fracture. Ulnar side of hand. Diagnosis is made with plain radiographs of the ankle. Additionally, lateral collateral ligament of the knee originates from the lateral epicondlye of the femur to insert on the superior portion of the fibular head and is the . The deep peroneal nerve is responsible for sensation over the first dorsal webspace. may be done supine with bump under affected limb or in lateral position. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint, 4. Full healing usually is accomplished by 68 weeks. isolated but, in general, the force required to fracture the fibula. Distal tibial physeal fractures in children that may require open reduction. Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury ( distal tibiofibular syndesmosis , deltoid ligament) and/or fracture of the medial malleolus. Summary. For distal tibial fractures, fixation of the fibula: May aid in realignment or length restoration of the tibial fracture, Increases the stability of the tibial fracture repair (, Is performed with a 3.5-mm compression plate. Wounds may be treated with vacuum-assisted closure. Nielson JH, Sallis JG, Potter HG, et al. Fibula and its ligaments in load transmission and ankle joint stability. Transverse comminuted fracture of the fibula above the level of the syndesmosis. Fractures of the fibula can be described by anatomic position as proximal, midshaft, or distal. One reason for this may be the treatment for the vast majority of isolated fibula shaft fractures is non-operative - this contrasts with the treatment of lateral malleolus fractures, which, although it is part of the fibula, technically, are categorized as ankle fractures and, therefore, have different treatment principles. a combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle), knee positioned at 90 and external rotation and valgus force applied to tibia, as the knee is extended the tibia reduces with a palpable clunk, tibia reduces from a posterior subluxed position at ~20 of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee), altered sensation to dorsum of foot and weak ankle dorsiflexion, approximately 25% of patients have peroneal nerve dysfunction, may see avulsion fracture of the fibula (arcuate fracture ) or femoral condyle, side-to-side difference 2.7-4 mm = isolated LCL tear, primary varus = tibiofemoral malalignment, secondary varus = LCL deficiency with increased lateral opening, triple varus = remaining PLC deficient, overall varus recurvatum alignment, necessary to determine mechanical axis and if a, look for injury to the LCL, popliteus, and biceps tendon, coronal oblique thin-slice through the fibular head are best at visualizing the PLC structures, hinged knee brace locked in extension x4 weeks, followed by progressive functional rehabilitation, midsubstance repair have 40% failure rate following repair, repair of LCL, popliteus tendon and/or popliteofibular ligament should be performed if structures can be, anatomically reduced to their attachment site, avulsion fracture of fibular head can be treated with screws or suture anchors, avulsion injuries where repair is not possible or tissie is poor quality, goal is to reconstruct LCL and the popliteofibular ligament using a free tendon graft (semitendinosus or achilles), soft tissue graft passed through bone tunnel in fibular head, limbs are then crossed to create figure-of-eight and fixed to lateral femur to a single tunnel, trans-tibial double-bundle reconstruction, split achilles tendon is fixed to isometric point of the femoral epicondyle, one tibia-based limb and one fibula-based limb, fibula-limb is fixed to the fibular head with a bone tunnel and transosseous sutures to reconstruct the LCL, tibia-limb is brought through the posterior tibia to reconstruct the popliteofibular ligament, proximal attachment site at anatomic femoral LCL attachment, through the fibular head lateral to medial, docking into the tibial tunnel posterior to anterior with graft #2, graft #2 reconstructs the popliteus tendon, proximal attachment site at the anatomic popliteus tendon attachment, docking into the tibial tunnel posterior to anterior with graft #1, hinged knee brace, nonweightbearing for 6 weeks, range of motion protocols differ between surgeons, some advocate for passive ROM immediately 0-90, others immobilize for 2 weeks, then begin motion, at 6 weeks, begin weightbearing and closed-chain strenghtening, return to activities / sports ~ 6 to 9 months, operative treatment has improved outcomes compared to nonoperative treatment, repair has higher failure rate than reconstruction, particularly for midsubstance injuries, but also for soft tissue avulsions, anatomic reconstruction restores rotatory stability, but not all varus stability on stress testing, PLC reconstruction, +/- ACL reconstruction, +/-, acute and chronic combined ligament injuries, PLC reconstruction should be performed at same time or prior to (as staged procedure) ACL or PCL to prevent early cruciate failure, indicated in patients with varus mechanical alignment, failure to correct bony alignment jeopardizes ACL and PLC reconstruction success, ACL reconstruction + PLC repair 33% achieved IKDC grade A or B compared to 88% of patients who underwent ACL + PLC reconstruction, failure to identify a PLC injury will lead to failure of ACL or PCL reconstruction, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Proximal Tibiofibular Joint Ganglion Cysts, Pre-Participation Physical Exam in Athlete, Concussions (Mild Traumatic Brain Injury). Similar to a nondisplaced medial malleolus fracture, a nondisplaced lateral malleolus fracture can often be treated with a short leg cast or walking boot. It's possible to fracture the fibula by placing too much pressure on it over and over again. Are you sure you want to trigger topic in your Anconeus AI algorithm? Sometimes they may also involve the fracture of the growth plate (physis) located at each end of the tibia. Rarely, a fracture of the fibula may be. Read More, Copyright 2007 Lippincott Williams & Wilkins. lawnmower) or iatrogenic during surgical dissection, (patterned off adult Lauge-Hansen classification), Adduction or inversion force avulses the distal fibular epiphysis (SH I or II), Rarely occurs with failure of lateral ligaments, Further inversion leads to distal tibial fracture (usually SH III or IV, but can be SH I or II), Occasionally can cause fracture through medial malleolus below the physis, Plantarflexion force displaces the tibial epiphysis posteriorly (SH I or II), Thurston-Holland fragment is composed of the posterior tibial metaphysis and displaces posteriorly, External rotation force leads to distal tibial fracture (SH II), Thurston-Holland fragment displaces posteromedially, Easily visible on AP radiograph (fracture line extends proximally and medially), Further external rotation leads to low spiral fracture of fibula (anteroinferior to posterosuperior), External rotation force leads to distal tibial fracture (SH I or II) and transverse fibula fracture, Occasionally can be transepiphyseal medial malleolus fracture (SH II), Distal tibial fragment displaces laterally, Thurston-Holland fragment is lateral or posterolateral distal tibal metaphysis, Can be associated with diastasis of ankle joint, Leads to SH V injury of distal tibial physis, Can be difficult to identify on initial presentation (diagnosis typically made when growth arrest is seen on follow-up radiographs), distal fibula physeal tenderness may represent non-displaced SHI, full-length tibia (or proximal tibia) to rule out Maisonneuve-type fracture, assess fracture displacement (best obtained post-reduction), non-displaced (< 2mm) isolated distal fibular fracture, displaced (> 2mm) SH I or II fracture with, acceptable closed reduction (no varus, < 10 valgus, < 10 recurvatum/procurvatum, < 3mm physeal widening), or II fracture with unacceptable closed reduction (varus, > 10 valgus, > 10 recurvatum/procurvatum, > 3mm physeal widening) and > 2 years of growth remaining, displaced SH I or II fracture with unacceptable closed reduction (varus, > 10 valgus, > 10 recurvatum/procurvatum, > 3mm physeal widening) and < 2 years of growth remaining, requires adequate sedation and muscle relaxation, only attempt reduction two times to prevent further physeal injury, NWB short-leg cast if isolated distal fibula fracture, NWB long-leg cast if distal tibia fracture, interposed periosteum, tendons, or neurovascular structures, percutaneous manipulation with K wires may aid reduction, open reduction may be required if interposed tissue present, transepiphyseal fixation best if at all possible, high rate associated with articular step-off > 2mm, medial malleolus SH IV fractures have the highest rate of growth disturbance, 15% increased risk of physeal injury for every 1mm of displacement, can represent periosteum entrapped in the fracture site, partial arrests can lead to angular deformity, distal fibular arrest results in ankle valgus defomity, medial distal tibia arrest results in varus deformity, complete arrests can result in leg-length discrepancy, if < 20 degrees of angulation with < 50% physeal involvement and > 2 years of growth remaining, bar of >50% physeal involvement in a patient with at least 2 years of growth, fibular epiphysiodesis helps prevent varus deformity, if < 50% physeal involvement and > 2 years of growth remaining, contralateral epiphysiodesis if near skeletal maturity with significant expected leg-length discrepancy, typically seen in posteriorly displaced fractures, can occur after triplane fractures, SH I or II fractures, usually leads to an increased external foot rotation angle, anterior angulation or plantarflexion deformity, occurs after supination-plantarflexion SH II fractures, occurs after external rotation SH II fractures, treatment options include physical therapy, psychological counseling, drug therapy, sympathetic blockade, Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). Medial malleolus transverse fracture or disruption of deltoid ligament . Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. performed with the hip flexed 45, knee flexed 80, and foot is ER 15. Login. Are you sure you want to trigger topic in your Anconeus AI algorithm? Treatment may be nonoperative or operative depending on patient age, fracture displacement, and fracture morphology. Pronation - External Rotation (PER) 1. traveling traction), placed in metaphyseal segment at the concavity of the deformity, posteriorly placed blocking screw in proximal fragment and laterally placed blocking screw in the metaphyseal fragment help direct the nail more centrally, avoiding valgus/procurvatum deformities, increase biomechanical stability of bone/implant construct by 25%, not associated with increased infections, wound complications, and nonunion compared to closed-nailing techniques, ensure fracture is reduced before reaming, overream by 1.0-1.5mm to facilitate nail insertion, confirm guide wire is appropriately placed prior to reaming, should be "center-center" in the coronal and sagittal planes distally at the physeal scar, anterior aspect of nail should be lined up with axis of tibia when inserting nail - typically should line up with 2nd metatarsal in absence of tibial deformity, statically lock proximal and distally for rotational stability, no indication for dynamic locking acutely, number of interlocking screws is controversial, two proximal and two distal screws in presence of <50% cortical contact, consider 3 interlock screws in short segment of distal or proximal shaft fracture, prefer multiplanar screw fixation in these short segments, lateral may have more soft tissue interference but may be preferred in setting of soft tissue/wound issues, generally, minimally invasive plating is used to preserve soft tissues, plate attached to external jig to allow for percutaneous insertion of screws, must ensure appropriate contour of plate to avoid malreduction, higher risk for wound issues, particularly in open fractures, superficial peroneal nerve (SPN) commonly at risk laterally, below knee amputation (BKA) vs. above knee amputation (AKA) based on degree of soft tissue damage, standard BKA vs. ertl/bone block technique, infrapatellar nailing with patellar tendon splitting and paratendon approach, suprapatellar nailing may have lower rate of anterior knee pain, more common if nail left proud proximally, lateral radiograph is best radiographic views to evaluate proximal nail position, pain relief unpredictable with nail removal, all tibial shaft fractures - between 8-10%, higher in proximal 1/3 tibia fractures - up to 50%, patellar tendon pulls proximal fragment into extension, while hamstring tendons and gastrocnemius pull the distal fragment into flexion (procurvatum), distal 1/3 fractures have a higher rate of valgus malunion with IM nailing compared to plating, definitive management with casting or external fixation, most common deformity is varus with nonsurgical management, varus malunion may place patient at risk for ipsilateral ankle pain and stiffness, starting point too medial with IM nailing, adequate reduction, proper start point when nailing, if malalignment is noted immediately after surgery, return to operating room is appropriate with removal of nail, reduction and nail reinsertion, if malunion is appreciated at later followup, eventual nail removal and tibial osteotomy can be considered, most appropriate for aseptic, diaphyseal tibial nonunions, oblique tibial shaft fractures have the highest rate of union when treated with exchange nailing, consider revision with plating in metaphyseal nonunions, BMP-7 (OP-1) has been shown equivalent to autograft, often used in cases of recalcitrant non-unions, compression plating has been shown to have a 92-96% union rate after open tibial fractures initially treated with external fixation, fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula, highest after IM nailing of distal 1/3 tibia fractures, increases risk of adjacent ankle arthrosis, should always assess rotation in operating room, obtain perfect lateral fluoroscopic image of knee, then rotate c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle, may have reduced risk with adjunctive fibular plating, LISS plate application without opening for distal screw fixation near plate holes 11-13 put superficial peroneal nerve at risk of injury due to close proximity, saphenous nerve can be injured during placement of locking screws, transient peroneal nerve palsy can be seen after closed nailing, EHL weakness and 1st dorsal webspace decreased sensation, usually nonoperatively with variable recovery expected, severe soft tissue injury with contamination, longer time to definitive soft tissue coverage, may require I&D or eventual removal of hardware, use of wound vacuum-assisted closure does not decrease risk of infection, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. This type of fracture usually results from high-energy trauma or penetrating wounds. Distal fibula fractures that involve the ankle joint are by far the most common fibula fractures (see . The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. Make linear longitudinal incision along the posterior border of the fibula (length depends on desired exposure) may extend proximally to a point 5cm proximal to the fibular head Accept These fractures are usually transverse (across) or oblique (slanted) breaks in the bone. 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Undecided - C1 diaphyseal fracture of the fibula, simple. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. This procedure involves placing a piece of foam in the wound and using a device to apply negative pressure to draw the edges of a wound together. Vaccines & Boosters | Testing | Visitor Guidelines | Coronavirus. Mechanism of Injury [edit | edit source]. Vertical medial malleolus and impaction of anteromedial distal tibia, 2. With an associated knee injury, patients have pain and swelling of the knee joint. Patients are counseled that, although fibula fractures. Fractures that involve syndesmotic injury or ankle or knee fracture often require surgical treatment. Open fractures of the tibia are common among children and adults. New masking guidelines are in effect starting April 24. The fibula is one of the two long bones in the leg, and, in contrast to the tibia, is a non-weight bearing bone in terms of the shaft. Epiphyseal fractures of the distal ends of the tibia and fibula. A common result of damage to the deep peroneal nerve is drop foot, in which there is a loss of the capacity to dorsiflex the foot. 2023 Lineage Medical, Inc. All rights reserved. Long-distance runners and hikers are at risk for stress fractures. 2023 - TeachMe Orthopedics. Description. Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. Are you sure you want to trigger topic in your Anconeus AI algorithm? (0/3), Level 2 Lauge Hansen classification: - classification: - C: fibula fracture above syndesmosis. counterpart of LeFortWagstaffe fracture), medial sided swelling, tenderness, and ecchymosis not sensitive for medial stability, palpate proximal fibula for Maisonneuve fracture, most appropriate stress radiograph to assess competency of deltoid ligament, foot dorsiflexed and ER with tibia stabilized, more sensitive to injury than medial tenderness, ecchymosis, or edema, gravity stress radiograph is equivalent to manual stress radiograph, difficult for patients to tolerate in acute setting, it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements, normal <6 mm on both AP and mortise views, bisection of line through tibial anatomical axis and line through tip of both malleoli, shortening of lateral malleoli fractures can lead to increased talocrural angle, talocrural angle is not 100% reliable for estimating restoration of fibular length, can also utilize realignment of the medial fibular prominence with the tibiotalar joint, 25% of surgeons would change operative technique after CT, assess for anteromedial impaction of tibial plafond and talar articular cartilage injury, axial and sagittal views most useful to assess posterior malleolus, size and shape of posterior malleolus fragment, evaluate for soft tissue or cartilaginous injuries, positive anterior drawer or talar tilt test, increased medial clear space or tibiofibular diastasis on stress view, inability or weakness with plantar flexion, increased resting dorsiflexion when prone with knees bent, Chaput fragment, Volkmann fragment, medial malleolus, central impaction, high energy with extensive soft tissue injury, 25% open, x-ray shows dislocation of talus from calcaneous or navicular bone, avulsion tip fractures of medial or lateral malleolus, bimalleolar or bimalleolar-equivalent fracture, posterior malleolar fracture with > 25% or > 2mm step-off, goal of treatment is stable anatomic reduction with restoration of mortise, see fracture patterns below for specific treatment, direct reduction of medial and lateral malleolus fractures, indirect reduction of posterior malleolus, facilitates direct reduction of posterior malleolus, common approach for fibula ORIF syndesmotic fixation, concomitant access to posterior fibula and posterior malleolus, access to medial malleolus and posterior malleolus, common approach for medial malleolus ORIF, prolonged recovery expected (2 years to obtain final functional result), anatomic reduction is considered most important factor for satisfactory outcome, ORIF superior to closed treatment of bimalleolar fractures, improved incisional perfusion with Allgwer-Donati sutures, proper braking response time (driving) returns to baseline at 9 weeks after surgery, braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of lower extremity, severe open fractures with gross contamination, poor soft tissue requiring close monitoring, lower risk of redislocation and skin complication in ankle fracture dislocation vs splint, isolated medial malleolus fracture without talar shift, deep deltoid inserts on posterior colliculus, good outcomes with >95% union rate for isolated injury, lag screw fixation stronger if placed perpendicular to fracture line, bicortical 3.5 mm fully-threaded screw (lag by technique) superior to unicortical 4.0 mm partially-threaded screw (lag by design), > 4-5 mm of medial clear space widening on stress views considered unstable, recent studies show deep deltoid intact with 8-10 mm of widening on stress view, open reduction and internal fixation (ORIF), presence of talar shift on static or stress view (bimalleolar equivalent), one-third tubular or anatomic distal fibular plate, stiffest fixation construct for the fibula is a locking plate, posterior antiglide plating is biomechanically superior to lateral plate, disadvantage of peroneal tendon irritation if plate too distal, newer implants have improved axial and rotational control with distal/proximal fixation, useful for poor soft-tissue envelopes or high risk for wound-healing complication, similar outcomes with operative and non-operative treatment if stable mortise, Bimalleolar-Equivalent Fracture (deltoid ligament tear with fibular fracture), low demand and unable to tolerate surgery, lateral malleolus fracture with talar shift (static or stress view), assess syndesmotic stability after fixation of lateral malleolus, not necessary to repair medial deltoid ligament, explore medially if unable to reduce mortise and deltoid ligament potentially interposed, lower rate of nonunion and fracture displacement with operative treatment, Bimalleolar (MEDIAL AND LATERAL) Fracture, low demand and unable to undergo surgical intervention, any displacement or talar shift (static or stress view), size should be calculated on CT since plain radiographs are unreliable, interval between FHL and peroneal tendons, common approach since posterior malleolus fractures are frequently posterolateral, decision of approach will depend on location of fracture, degree of displacement, and need for fibular fixation, stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus vs 40% with isolated, PITFL may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation, stress examination of syndesmosis still required after posterior malleolar fixation, 40-90% of distal third spiral tibia fractures have an associated posterior malleolus fracture, rare fracture-dislocation of ankle where fibula is entrapped behind tibia and is irreducible, posterolateral ridge of the distal tibia hinders reduction of the fibula, open reduction of fibula and internal fixation is required, fracture-dislocation of the ankle due to hyperplantarflexion, main feature is a vertical shear fracture of the posteromedial tibial rim, double cortical density at the inferomedial tibial metaphysis, ORIF of posterior malleolus with antiglide plating, primary closure at index procedure can be performed in appropriately-selected grade I, II, and IIIA open fractures in otherwise healthy patients without gross contamination, higher incidence with higher fibula fractures, fixation usually not required when fibula fracture within 4.5 cm of plafond, measure tibiofibular clear space 1 cm above joint, abduction/external rotation stress of dorsiflexed foot, lateral stress radiograph has greater interobserver reliability than an AP/mortise stress film, instability of the syndesmosis is greatest in the anterior-posterior direction, patient placed in lateral decubitus position, similar effectiveness to manual ER stress test, bone hook around fibula used to pull while placing counter traction on tibia, tibiofibular clear space (AP) greater than 5 mm, length and rotation of fibula must be accurately restored, "Dime sign"/Shentons line to determine length of fibula, fixing lateral and/or posterior malleolus first my obviate need for syndesmotic fixation, outcomes are strongly correlated with anatomic reduction, maximum dorsiflexion not required during screw placement (over-tightening), open reduction required if closed reduction unsuccessful or questionable, one or two cortical screw(s) or suture-button devices 2-4 cm above joint, angled posterior to anterior 20-30 degrees (fibula posterior to tibia), suture button has lower rate of malreduction and reoperation rate than screws, no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year, outcome may be worse with maintenance of intact screws, screws should be maintained in place for at least 8-12 weeks, must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation, any postoperative malalignement or widening should be treated with open debridement, reduction, and fixation, Diabetic Ankle Fractures (with or without Neuropathy), poor circulation impairs wound and fracture healing, multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury), tibiotalar Steinmann pins or hindfoot nailing, augment with intramedullary fibula K-wires, stiffer, more rigid fibular plates (instead of 1/3 tubular plates), maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients), largest risk factor for diabetic patients is presence of, articular impaction of tibial plafond in SAD injuries should be addressed at time of surgery, corrective osteotomy requires obtaining anatomic fibular length and mortise correction for optimal outcomes, Loss of dorsiflexion with posterior fixation, rare with anatomic reduction and fixation, very common in "log-splitter" type injuries (trans-syndesmotic fracture-dislocations in which the talus is driven into the distal tibiofibular articulation), superficial peroneal nerve injury (10-15%), At risk with lateral approach to distal fibula, posterolateral, and anterior/anterolateral approaches, Two terminal nerve branches that innervate dorsum of the foot, protruding screw head in most distal hole of fibula plate, at risk with posterior medial malleolus screw placement, Excellent for stable ankle fractures treated nonoperatively, Outcomes following operative treatment generally very favorable, 90% mild/no ankle pain with minimal limitations and near full functional recovery at 1 yr, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries.

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