Progress in diagnosis and treatment of fibular fracture in ankle fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

TANG Yiding ¹ ,  LIANG Xiaojun ² , ZHAO Hongmou ² , ZHANG Yan ²

1. Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Medical College, Xi’an Shaanxi, 710054, P. R. China;
2. Department of Foot and Ankle Surgery, Honghui Hospital Affiliated to Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P. R. China;

Corresponding author：

LIANG Xiaojun, Email: lxj33369@163.com

Keywords：

Ankle fracture; fibular fracture; diagnosis; conservative treatment; surgical treatment

DOI：

10.7507/1002-1892.202108091

Video：

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Objective To summarize the diagnosis and treatment of fibular fracture in ankle fracture. Methods Relevant literature at home and abroad in recent years was widely consulted, and various types of fractures were discussed and summarized according to Danis-Weber classification. Results Conservative treatment is not an ideal treatment for type A avulsion fracture. The operation method should be determined according to the position and size of bone mass. For simple type B fracture, both conservative treatment and surgical treatment can achieve good results. When the position of type C fracture is high and does not affect the stability of ankle joint, it can be treated conservatively, while when the position is low and affects the stability of ankle joint, it needs surgical treatment. Conclusion First of all, whether the fibular fracture in the ankle fracture is stable or not should be determined. Whether it is treated surgically or not, the purpose is to restore the tibiofibular syndesmosis and restore the motor function of the ankle.

Citation： TANG Yiding, LIANG Xiaojun, ZHAO Hongmou, ZHANG Yan. Progress in diagnosis and treatment of fibular fracture in ankle fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(1): 117-121. doi: 10.7507/1002-1892.202108091 Copy

1.	Egger AC, Berkowitz MJ. Operative treatment of the malunited fibula fracture. Foot Ankle Int, 2018, 39(10): 1242-1252.
2.	Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma, 2007, 21(5): 307-315.
3.	van Dijk CN, Vuurberg G. There is no such thing as a simple ankle sprain: clinical commentary on the 2016 International Ankle Consortium position statement. Br J Sports Med, 2017, 51(6): 485-486.
4.	Yamaguchi S, Akagi R, Kimura S, et al. Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. Knee Surg Sports Traumatol Arthrosc, 2019, 27(9): 2774-2780.
5.	El Ashry SR, El Gamal TA, Platt SR. Atypical chronic ankle instability in a pediatric population secondary to distal fibula avulsion fracture nonunion. J Foot Ankle Surg, 2017, 56(1): 148-152.
6.	Porter DA, Kamman KA. Chronic lateral ankle instability: Open surgical management. Foot Ankle Clin, 2018, 23(4): 539-554.
7.	Haraguchi N, Kato F, Hayashi H. New radiographic projections for avulsion fractures of the lateral malleolus. J Bone Joint Surg (Br), 1998, 80(4): 684-688.
8.	Noh JH, Yang BG, Yi SR, et al. Outcome of the functional treatment of first-time ankle inversion injury. J Orthop Sci, 2010, 15(4): 524-530.
9.	Takakura Y, Yamaguchi S, Akagi R, et al. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. BMC Musculoskelet Disord, 2020, 21(1): 276. doi: 10.1186/s12891-020-03287-1.
10.	Boutis K, Plint A, Stimec J, et al. Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain? JAMA Pediatr, 2016, 170(1): e154114. doi: 10.1001/jamapediatrics.2015.4114.
11.	Diallo J, Wagener J, Schweizer C, et al. Intraoperative findings of lateral ligament avulsion fractures and outcome after refixation to the fibula. Foot Ankle Int, 2018, 39(6): 669-673.
12.	Kwak YH, Lim JY, Oh MK, et al. Radiographic diagnosis of occult distal fibular avulsion fracture in children with acute lateral ankle sprain. J Pediatr Orthop, 2015, 35(4): 352-357.
13.	Haraguchi N, Toga H, Shiba N, et al. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med, 2007, 35(7): 1144-1152.
14.	Kim BS, Choi WJ, Kim YS, et al. The effect of an ossicle of the lateral malleolus on ligament reconstruction of chronic lateral ankle instability. Foot Ankle Int, 2010, 31(3): 191-196.
15.	Gamble JG. Type Ⅶ all-epiphyseal fractures of the lateral malleolus and the origin of subfibular ossicles. J Pediatr Orthop, 2020, 40(9): e839-e843.
16.	Lee DY, Lee DJ, Kim DH, et al. Posttraumatic subfibular ossicle formation in children: Experience in a single primary care unit. J Pediatr Orthop, 2018, 38(9): e530-e535.
17.	White WJ, McCollum GA, Calder JD. Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1124-1129.
18.	Reiner MM, Sharpe JJ. The role of the accessory malleolar ossicles and malleolar avulsion fractures in lateral ankle ligament reconstruction. Foot Ankle Spec, 2018, 11(4): 308-314.
19.	Zhang C, Wang X, Ma X, et al. A novel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: a cadaveric study. Surg Radiol Anat, 2014, 36(3): 281-288.
20.	Kortekangas T, Haapasalo H, Flinkkilä T, et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ, 2019, 364: k5432. doi: 10.1136/bmj.k5432.
21.	van Leeuwen CAT, Hoffman RPC, Donken CCMA, et al. The diagnosis and treatment of isolated type B fibular fractures: Results of a nationwide survey. Injury, 2019, 50(2): 579-589.
22.	Mittal R, Harris IA, Adie S, et al. Surgery for type B ankle fracture treatment: a combined randomised and observational study (CROSSBAT). BMJ Open, 2017, 7(3): e013298. doi: 10.1136/bmjopen-2016-013298.
23.	van Leeuwen CAT, Hoffman RPC, Hoogendoorn JM. Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures. Injury, 2019, 50(12): 2318-2323.
24.	McConnell T, Creevy W, Tornetta P. Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg (Am), 2004, 86(10): 2171-2178.
25.	van Leeuwen C, Haak T, Kop M, et al. The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures. Eur J Trauma Emerg Surg, 2019, 45(4): 727-735.
26.	Deml C, Eichinger M, van Leeuwen WF, et al. Does intra-articular load distribution change after lateral malleolar fractures? An in vivo study comparing operative and non-operative treatment. Injury, 2017, 48(4): 854-860.
27.	Bitar RC, Nishikawa DRC, de Cesar Netto C, et al. A short single-incision approach for antiglide plate fixation of oblique fractures of the lateral malleolus: a technical tip. Eur J Orthop Surg Traumatol, 2021, 31(2): 407-412.
28.	Chiang CC, Tzeng YH, Lin CC, et al. Minimally invasive versus open distal fibular plating for AO/OTA 44-B ankle fractures. Foot Ankle Int, 2016, 37(6): 611-619.
29.	Chiang CC, Tzeng YH, Lin CFJ, et al. Arthroscopic reduction and minimally invasive surgery in supination-external rotation ankle fractures: A comparative study with open reduction. Arthroscopy, 2019, 35(9): 2671-2683.
30.	Ebraheim NA, Maten JWV, Delaney JR, et al. Cannulated intramedullary screw fixation of distal fibular fractures. Foot Ankle Spec, 2019, 12(3): 264-271.
31.	Bartoníček J, Rammelt S, Kašper Š, et al. Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg, 2019, 139(4): 497-506.
32.	Guo H, Huang W, Zeng C. Ankle Fracture with a complex injury mechanism and misleading hook test result: A case report. J Foot Ankle Surg, 2020, 59(6): 1275-1278.
33.	Yde J. The Lauge Hansen classification of malleolar fractures. Acta Orthop Scand, 1980, 51(1): 181-192.
34.	He JQ, Ma XL, Xin JY, et al. Pathoanatomy and injury mechanism of typical maisonneuve fracture. Orthop Surg, 2020, 12(6): 1644-1651.
35.	Yu GS, Lin YB, Xiong GS, et al. Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review. Int Orthop, 2019, 43(11): 2539-2547.
36.	Sipahioglu S, Zehir S, Isikan E. Weber C ankle fractures with tibiofibular diastasis: syndesmosis-only fixation. Acta Ortop Bras, 2017, 25(3): 67-70.
37.	Ho JY, Ren Y, Kelikian A, et al. Mid-diaphyseal fibular fractures with syndesmotic disruption: should we plate the fibula? Foot Ankle Int, 2008, 29(6): 587-592.
38.	Mohammed R, Syed S, Metikala S, et al. Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury. Indian J Orthop, 2011, 45(5): 454-458.
39.	Bäcker HC, Vosseller JT. Fibular nail fixation: Topical review. Foot Ankle Int, 2019, 40(11): 1331-1337.
40.	Al-Obaidi B, Wiik AV, Bhattacharyya R, et al. Fibular nails for open and closed ankle fractures: Results from a non-designer level Ⅰ major trauma centre. J Orthop Surg (Hong Kong), 2019, 27(1): 2309499019832420. doi: 10.1177/2309499019832420.
41.	Marazzi C, Wittauer M, Hirschmann MT, et al. Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures. J Orthop Surg Res, 2020, 15(1): 491. doi: 10.1186/s13018-020-02018-5.
42.	Boni G, Sanchez GT, Arliani G, et al. Safety and efficacy of surgical fixation of fibula fractures using an intramedullary nail: a retrospective observational cohort study in 30 patients. Patient Saf Surg, 2019, 13: 31. doi: 10.1186/s13037-019-0211-7.
43.	Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma, 2020, 11(3): 375-379.

1. Egger AC, Berkowitz MJ. Operative treatment of the malunited fibula fracture. Foot Ankle Int, 2018, 39(10): 1242-1252.
2. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma, 2007, 21(5): 307-315.
3. van Dijk CN, Vuurberg G. There is no such thing as a simple ankle sprain: clinical commentary on the 2016 International Ankle Consortium position statement. Br J Sports Med, 2017, 51(6): 485-486.
4. Yamaguchi S, Akagi R, Kimura S, et al. Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. Knee Surg Sports Traumatol Arthrosc, 2019, 27(9): 2774-2780.
5. El Ashry SR, El Gamal TA, Platt SR. Atypical chronic ankle instability in a pediatric population secondary to distal fibula avulsion fracture nonunion. J Foot Ankle Surg, 2017, 56(1): 148-152.
6. Porter DA, Kamman KA. Chronic lateral ankle instability: Open surgical management. Foot Ankle Clin, 2018, 23(4): 539-554.
7. Haraguchi N, Kato F, Hayashi H. New radiographic projections for avulsion fractures of the lateral malleolus. J Bone Joint Surg (Br), 1998, 80(4): 684-688.
8. Noh JH, Yang BG, Yi SR, et al. Outcome of the functional treatment of first-time ankle inversion injury. J Orthop Sci, 2010, 15(4): 524-530.
9. Takakura Y, Yamaguchi S, Akagi R, et al. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children: a diagnostic accuracy study comparing ultrasonography with radiography. BMC Musculoskelet Disord, 2020, 21(1): 276. doi: 10.1186/s12891-020-03287-1.
10. Boutis K, Plint A, Stimec J, et al. Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain? JAMA Pediatr, 2016, 170(1): e154114. doi: 10.1001/jamapediatrics.2015.4114.
11. Diallo J, Wagener J, Schweizer C, et al. Intraoperative findings of lateral ligament avulsion fractures and outcome after refixation to the fibula. Foot Ankle Int, 2018, 39(6): 669-673.
12. Kwak YH, Lim JY, Oh MK, et al. Radiographic diagnosis of occult distal fibular avulsion fracture in children with acute lateral ankle sprain. J Pediatr Orthop, 2015, 35(4): 352-357.
13. Haraguchi N, Toga H, Shiba N, et al. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Am J Sports Med, 2007, 35(7): 1144-1152.
14. Kim BS, Choi WJ, Kim YS, et al. The effect of an ossicle of the lateral malleolus on ligament reconstruction of chronic lateral ankle instability. Foot Ankle Int, 2010, 31(3): 191-196.
15. Gamble JG. Type Ⅶ all-epiphyseal fractures of the lateral malleolus and the origin of subfibular ossicles. J Pediatr Orthop, 2020, 40(9): e839-e843.
16. Lee DY, Lee DJ, Kim DH, et al. Posttraumatic subfibular ossicle formation in children: Experience in a single primary care unit. J Pediatr Orthop, 2018, 38(9): e530-e535.
17. White WJ, McCollum GA, Calder JD. Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4): 1124-1129.
18. Reiner MM, Sharpe JJ. The role of the accessory malleolar ossicles and malleolar avulsion fractures in lateral ankle ligament reconstruction. Foot Ankle Spec, 2018, 11(4): 308-314.
19. Zhang C, Wang X, Ma X, et al. A novel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: a cadaveric study. Surg Radiol Anat, 2014, 36(3): 281-288.
20. Kortekangas T, Haapasalo H, Flinkkilä T, et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ, 2019, 364: k5432. doi: 10.1136/bmj.k5432.
21. van Leeuwen CAT, Hoffman RPC, Donken CCMA, et al. The diagnosis and treatment of isolated type B fibular fractures: Results of a nationwide survey. Injury, 2019, 50(2): 579-589.
22. Mittal R, Harris IA, Adie S, et al. Surgery for type B ankle fracture treatment: a combined randomised and observational study (CROSSBAT). BMJ Open, 2017, 7(3): e013298. doi: 10.1136/bmjopen-2016-013298.
23. van Leeuwen CAT, Hoffman RPC, Hoogendoorn JM. Long-term outcome in operatively and non-operatively treated isolated type B fibula fractures. Injury, 2019, 50(12): 2318-2323.
24. McConnell T, Creevy W, Tornetta P. Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg (Am), 2004, 86(10): 2171-2178.
25. van Leeuwen C, Haak T, Kop M, et al. The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures. Eur J Trauma Emerg Surg, 2019, 45(4): 727-735.
26. Deml C, Eichinger M, van Leeuwen WF, et al. Does intra-articular load distribution change after lateral malleolar fractures? An in vivo study comparing operative and non-operative treatment. Injury, 2017, 48(4): 854-860.
27. Bitar RC, Nishikawa DRC, de Cesar Netto C, et al. A short single-incision approach for antiglide plate fixation of oblique fractures of the lateral malleolus: a technical tip. Eur J Orthop Surg Traumatol, 2021, 31(2): 407-412.
28. Chiang CC, Tzeng YH, Lin CC, et al. Minimally invasive versus open distal fibular plating for AO/OTA 44-B ankle fractures. Foot Ankle Int, 2016, 37(6): 611-619.
29. Chiang CC, Tzeng YH, Lin CFJ, et al. Arthroscopic reduction and minimally invasive surgery in supination-external rotation ankle fractures: A comparative study with open reduction. Arthroscopy, 2019, 35(9): 2671-2683.
30. Ebraheim NA, Maten JWV, Delaney JR, et al. Cannulated intramedullary screw fixation of distal fibular fractures. Foot Ankle Spec, 2019, 12(3): 264-271.
31. Bartoníček J, Rammelt S, Kašper Š, et al. Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg, 2019, 139(4): 497-506.
32. Guo H, Huang W, Zeng C. Ankle Fracture with a complex injury mechanism and misleading hook test result: A case report. J Foot Ankle Surg, 2020, 59(6): 1275-1278.
33. Yde J. The Lauge Hansen classification of malleolar fractures. Acta Orthop Scand, 1980, 51(1): 181-192.
34. He JQ, Ma XL, Xin JY, et al. Pathoanatomy and injury mechanism of typical maisonneuve fracture. Orthop Surg, 2020, 12(6): 1644-1651.
35. Yu GS, Lin YB, Xiong GS, et al. Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review. Int Orthop, 2019, 43(11): 2539-2547.
36. Sipahioglu S, Zehir S, Isikan E. Weber C ankle fractures with tibiofibular diastasis: syndesmosis-only fixation. Acta Ortop Bras, 2017, 25(3): 67-70.
37. Ho JY, Ren Y, Kelikian A, et al. Mid-diaphyseal fibular fractures with syndesmotic disruption: should we plate the fibula? Foot Ankle Int, 2008, 29(6): 587-592.
38. Mohammed R, Syed S, Metikala S, et al. Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury. Indian J Orthop, 2011, 45(5): 454-458.
39. Bäcker HC, Vosseller JT. Fibular nail fixation: Topical review. Foot Ankle Int, 2019, 40(11): 1331-1337.
40. Al-Obaidi B, Wiik AV, Bhattacharyya R, et al. Fibular nails for open and closed ankle fractures: Results from a non-designer level Ⅰ major trauma centre. J Orthop Surg (Hong Kong), 2019, 27(1): 2309499019832420. doi: 10.1177/2309499019832420.
41. Marazzi C, Wittauer M, Hirschmann MT, et al. Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures. J Orthop Surg Res, 2020, 15(1): 491. doi: 10.1186/s13018-020-02018-5.
42. Boni G, Sanchez GT, Arliani G, et al. Safety and efficacy of surgical fixation of fibula fractures using an intramedullary nail: a retrospective observational cohort study in 30 patients. Patient Saf Surg, 2019, 13: 31. doi: 10.1186/s13037-019-0211-7.
43. Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma, 2020, 11(3): 375-379.

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