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Distal Fibular Fracture

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Other Names

  • Weber Fracture
  • Isolated Lateral Malleolus Fractures
  • Weber A lateral malleolus fracture
  • Weber B lateral malleolus fracture
  • Weber C lateral malleolus fracture

Background

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


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

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

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


References

  1. 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.
  2. 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. 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.
  4. 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.
  5. 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.
  6. https://radiopaedia.org/cases/7965
  7. Murphy JM, Kadakia AR, Schilling PL, Irwin TA: Relationship among radiographic ankle medial clear space, sex, and height. Orthopedics 2014;37:e449-e454.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. Case courtesy of Assoc Prof Frank Gaillard. https://radiopaedia.org/cases/9642
  19. Weber B: Die verletzungen des oberen sprunggelenkes [German]. Bern, Hans Huber, 1972.
  20. 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.
  21. 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.
  22. 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.
Created by:
John Kiel on 11 June 2021 18:53:40
Authors:
Last edited:
4 October 2021 14:58:25
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute