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Distal Fibular Fracture
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(Redirected from Distal Fibula Fracture)
Other Names
- Weber Fracture
- Isolated Lateral Malleolus Fractures
- Weber A lateral malleolus fracture
- Weber B lateral malleolus fracture
- Weber C lateral malleolus fracture
Background
- This page refers to fractures of the distal Fibula
- Ankle Fracture is discussed separately
History
Epidemiology
- General
- Likely most common fracture pattern in the lower extremity
- Isolated lateral malleolus fractures are the most common ankle fracture pattern
- Represent 56% to 65% of all ankle fractures[1]
- Incidence
- 100-184 per 100,000 people per year[2]
Pathophysiology
- General
- Isolated lateral malleolus fractures are the most common ankle fracture pattern
- Management is generally dependent on the stability of the ankle mortise
- Stable
- Isolated lateral malleolus fractures without lateral subluxation of the talus [3]
- Low chance of displacement
- Do well with nonsurgical management
- Unstable
- Lateral malleolus fractures that have an incongruent ankle mortise[4]
- Considered unstable, require surgical fixation
- Etiology/ mechanism
- Weber A: Inversion injury
- Weber B: supination, external rotation
- Weber C: pronated, externally rotated
Associated Pathology
Pathoanatomy
Risk Factors
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
Clinical Features
- History
- Patients will describe an acute mechanism
- Pain, swelling of lateral ankle
- Inability to weight bear
- Physical Exam: Physical Exam Ankle
- Swelling, bruising will often be observed
- Deformity may or not be present
- Tenderness along distal fibula, possibly crepitus
- Medial-sided tenderness, swelling, and ecchymosis can suggest deltoid ligament injury
- Neither sensitive (57%), nor specific (59%)[5]
- Range of motion will be restricted
- Special Tests
Evaluation
- Consider use of Ottawa Ankle Rules
Weber A fracture[6]
Radiographs
- Standard Ankle Radiographs
- At a minimum, but strongly encouraged to check foot, tibfib and knee
- Critical to determine stability of joint
- Medial Clear Space (MCS)
- Evaluated on mortise view of standard radiographs
- Widening is suggestive of deltoid ligament injury, ankle instability
- Normal: 3.8 ± 0.7 mm (males), 2.9 ± 0.5 mm (females)[7]
- Can have false positive in tall patients
- False positive rates using cutoffs 3 mm (88.5%), 4 mm (53.6%), ≥5 mm (26.9%), and ≥6 mm (7.7%)[8]
- In general, widening MCS can not be predicted on standard mortise views
Stress Radiographs Ankle

Demonstration of manual ankle stress view[9]
- Stress Radiographs Ankle
- Standard of care to detect tibiotalar instability, especially of Weber B fractures
- Can be manual external rotation stress radiographs, gravity stress or weight bearing
- Superiority of one technique over another has not been determined
- Manual external rotation stress radiographs
- Performed by manually internally rotating the tibia approximately 10°
- Simultaneously applying an external rotation to the foot with the ankle in neutral dorsiflexion
- Reproducibility of test is challenging
- Amount of force necessary has not been determined
- Park et al: cadaveric studies found sensitivity, specificity, PPV, and NPV of 100% for absolute MCS > 5mm (manual stress radiographs)[10]
- Schottel et al: found sensitivity (66%), specificity (77%) for deltoid ligament tears confirmed by MRI[11]

Demonstration of gravity ankle stress view[12]
- Gravity stress radiographs
- Patient is in lateral decubitus position, injured side down
- Distal half of the leg is then placed over the end of the table
- This allows the foot to fall into external rotation because of gravity
- Benefits
- No radiation exposure to physician
- Force of gravity is constant, predictable
- Position of ankle does not affect the examination
- Two studies have demonstrated gravity stress views as effective as manual stress views, less painful to patients[13][14]
- Weight bearing stress radiographs
- Hoshino found patients with stable weight bearing films at 7 day follow up had excellent outcomes[15]
- Holmes et al had similar excellent outcomes using a MCS cutoff of 7 mm[16]
- Downside
- May be influenced by amount of weight patient is willing to put on affected limb
- Benefits
- Not influenced by ankle position
- Rely on constant force of gravity
- Less painful for patients
- Factors associated with stability from Nortunen et al[17]
- Maximum width of the fracture line on the lateral radiograph of < 2 mm
- Only two fracture fragments
- Female sex
- However, specificity was between 13% and 39% with a very high false negative rate
- Unstable findings
- Lateral translation of the talus
- Talar tilting on standard non–weight-bearing radiographs (suggests deltoid disruption)
MRI
- Limited utility
- Not recommended in clinical decision making
- Due to marked variability seen in measurement of similar MRI findings
Classification

Illustration of weber classification for distal fibula fractures.[18]
Danis-Weber Classification
- Describes the radiographic position of the distal fibula fracture in relation to the syndesmosis[19]
- Type A
- Fracture: occur below the level of the syndesmosis
- Stability: stable fracture patterns
- Type B fractures
- Correspond to the SER pattern described Lauge-Hansen classification
- Fracture: originate at the level of the syndesmosis
- Stability: may or may not be stable
- Type C fractures
- Location: occur above the level of the syndesmosis
- Stability: most often unstable injuries
Management
Prognosis
- Unstable fractures managed non-surgically
- Greater risk of displacement, nonunion, delayed union compared to surgical management[20]
- Increased risk of post-traumatic Ankle Osteoarthritis[3]
- Yde et al: follow-up of 3-10 years nonanatomic reduction managed surgically had a good functional result (83%), compared nonsurgical management (55%)[21]
- Egol et al[22]
- In patients with widening of joint space on stress radiographs without evidence of deltoid ligament injury
- Managed nonsurgically had good or excellent clinical results (AOFAS scores)
- Risk factors that predict Surgical Complication
- Diabetes Mellitus
- Peripheral Vascular Disease
- Advanced age
- Smoking
- Alcoholism
- Obesity
- Osteoporosis
- Soft tissue injury at the time of the fracture
Nonoperative
- Weber A Indications
- Virtually all cases
- Weber B Indications
- Absence of widening of medial clearspace
- Absence of talar subluxation or lateral translation
- Somewhat controversial
- Stable standard radiographs, instability on stress radiographs
- Short Leg Splint or Short Leg Cast
- Typically for 2-3 weeks
- Decision driven by degree of pain, stability
- Tall Wallking Boot
- Safe for Weber A fractures
- Transition to walking boot from cast/splint
- Physical Therapy
- Early range of motion exercises
- Repeat weight bearing xrays at about 6 weeks
- Many physicians will repeat more frequently
Operative
- Indications
- Weber C fracture
- Lateral translation of talus
- Medial malleolus fracture
- Technique
- Open reduction, internal fixation
- Minimally invasive plate osteosynthesis (MIPO)
- Intramedullary (IM) fixation
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications
- Post-traumatic Ankle Osteoarthritis
- Surgical
- Complications range from 5-60%<Ref>Bazarov, Irina, et al. "Minimally invasive plate osteosynthesis for treatment of ankle fractures in high-risk patients." The Journal of Foot and Ankle Surgery 57.3 (2018): 494-500./ref>
- Wound infection
- Hardware failure
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ Jehlicka D, Bartonicek J, Svatos F, Dobias J: Fracture-dislocations of the ankle joint in adults. Part I: Epidemiologic evaluation of patients during a 1-year period [Czech]. Acta Chir Orthop Traumatol Cech 2002;69:243-247.
- ↑ Elsoe, Rasmus, Svend E. Ostgaard, and Peter Larsen. "Population-based epidemiology of 9767 ankle fractures." Foot and Ankle Surgery 24.1 (2018): 34-39.
- ↑ 3.0 3.1 Gougoulias N, Khanna A, Sakellariou A, Maffulli N: Supination-external rotation ankle fractures: Stability a key issue. Clin Orthop Relat Res 2010;468:243-251.
- ↑ Makwana NK, Bhowal B, Harper WM, Hui AW: Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age: A prospective, randomised study. J Bone Joint Surg Br 2001;83:525-529.
- ↑ DeAngelis NA, Eskander MS, French BG: Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma 2007;21:244-247.
- ↑ https://radiopaedia.org/cases/7965
- ↑ Murphy JM, Kadakia AR, Schilling PL, Irwin TA: Relationship among radiographic ankle medial clear space, sex, and height. Orthopedics 2014;37:e449-e454.
- ↑ Schuberth JM, Collman DR, Rush SM, Ford LA: Deltoid ligament integrity in lateral malleolar fractures: A comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 2004;43:20-29.
- ↑ Aiyer, Amiethab A., et al. "Management of isolated lateral malleolus fractures." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 27.2 (2019): 50-59.
- ↑ Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ: Stress radiographs after ankle fracture: The effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma 2006;20:11-18.
- ↑ Schottel, Patrick C., et al. "Manual stress ankle radiography has poor ability to predict deep deltoid ligament integrity in a supination external rotation fracture cohort." The Journal of Foot and Ankle Surgery 54.4 (2015): 531-535.
- ↑ Aiyer, Amiethab A., et al. "Management of isolated lateral malleolus fractures." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 27.2 (2019): 50-59.
- ↑ Schock HJ, Pinzur M, Manion L, Stover M: The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89: 1055-1059
- ↑ LeBa TB, Gugala Z, Morris RP, Panchbhavi VK: Gravity versus manual external rotation stress view in evaluating ankle stability: A prospective study. Foot Ankle Spec 2015;8:175-179.
- ↑ Hoshino CM, Nomoto EK, Norheim EP, Harris TG: Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int 2012;33:92-98.
- ↑ Holmes JR, Acker WB II, Murphy JM, McKinney A, Kadakia AR, Irwin TA: A novel algorithm for isolated Weber B ankle fractures: A retrospective review of 51 nonsurgically treated patients. J Am Acad Orthop Surg 2016;24:645-652.
- ↑ Nortunen S, Leskela HV, Haapasalo H, Flinkkila T, Ohtonen P, Pakarinen H: Dynamic stress testing is unnecessary for unimalleolar supination-external rotation ankle fractures with minimal fracture displacement on lateral radiographs. J Bone Joint Surg Am 2017;99:482-487.
- ↑ Case courtesy of Assoc Prof Frank Gaillard. https://radiopaedia.org/cases/9642
- ↑ Weber B: Die verletzungen des oberen sprunggelenkes [German]. Bern, Hans Huber, 1972.
- ↑ Sanders DW, Tieszer C, Corbett B; Canadian Orthopedic Trauma Society: Operative versus nonoperative treatment of unstable lateral malleolar fractures: A randomized multicenter trial. J Orthop Trauma 2012;26:129-134.
- ↑ Yde J, Kristensen KD. Ankle fractures: Supination-eversion fractures of stage IV. Primary and late results of operative and non-operative treatment. Acta Orthop Scand 1980;51:981-990.
- ↑ Egol KA, Amirtharajah M, Tejwani NC, Capla EL, Koval KJ: Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004;86-A:2393-2398.