FIBULA SHAFT FRACTURES

Introduction

Fibula fractures often occur in association with fractures of the tibia.

Fractures of the tibia generally are associated with fibula fracture, because the force is
transmitted along the interosseous membrane to the fibula.

The predominant consideration when both bones are fractured will be the tibia. Of these
two bones, the tibia is the only weightbearing bone.

Isolated fractures of the fibula apart from those which are distal and involve the ankle
joint complex, are usually fairly benign and may be treated conservatively in most cases.

Isolated midshaft or proximal fibula fractures are relatively uncommon.

Maisonneuve fractures are fractures of the proximal fibula that occur in association
with fractures of the tibia at the level of the ankle joint.

See also separate guidelines for ankle fractures.

Mechanism

The usual mechanism of isolated fibula fracture is a direct blow.

Maisonneuve fractures:

Maisonneuve fractures involve a fracture of the proximal third of the

fibula in association with a fractured medial malleolus (or injured deltoid
ligament) with resulting diastasis of the distal tibiofibular syndesmosis.

It results from a forceful external rotation of the ankle with transmission of

forces through the distal tibiofibular syndesmosis. The force is transmitted
proximally and dissipated by fracture of the fibula.

This type of injury usually involves an abduction and external rotation

force on the ankle.

Maisonneuve fractures are relatively uncommon and are considered

unstable ankle injuries.
Complications

1. Peroneal nerve injury:

Fractures around the neck of the fibula may be associated with damage to
the peroneal nerve.

2. Ankle joint disruption:

Fractures around the lower third of the fibula will involve the ankle joint,
with the attendant added complications associated with injuries of this
joint.

3. Compound injury:

In contrast to the tibia, the fibula is well covered by soft tissue (muscle)
over most of its course (with the exception of the lateral malleolus) and so
compound injury is less common that is seen with tibial shaft fractures.

Clinical Features

1. Pain is usually mild to moderate only.

2. There may be swelling, but this may not be obvious, point tenderness will locate
the fracture site otherwise.

3. Neurovascular status of the lower limb should be checked.

Peroneal nerve injury, in particular needs to be excluded when the

fracture involves the proximal segment of the bone.

4. Maisonneuve injury:

It is important to note that when patients present with an injury to the

medial ankle, this may act as a distracting injury for an associated
Maisonneuve fracture of the proximal fibula.

This injury should be looked for in any patient who presents with an ankle
fracture.

Patients present with proximal fibular pain in addition to medial ankle

pain.

Investigations

Plain radiography:

Plain radiography will make the diagnosis in most cases.

 When imaging ankle fractures it is important to image the entire fibula if there is
any suggestion of associated proximal fibula pain so that a Maisonneuve fracture
is not missed.

See Appendix 1 below

Bone Scan/ CT & MRI Scan

These may be required to pick up more subtle hairline type fractures of the
fibula that are sometimes seen in sporting injuries.

Management

1. Analgesia as clinically indicated.

Oral analgesia will usually be sufficient in isolated fibula fractures

Titrated IV narcotic analgesia may be require for more complex ankle

joint injuries

2. Isolated fracture of the mid and upper fibula shaft:

Note that fractures of the lower quarter of the fibula are treated as ankle
fractures, (Weber type C).

With regard to isolated fractures of the upper and mid fibula shaft:

As the fibula is a non -weight bearing bone fractures can usually be treated
conservatively, provided the ankle joint is intact and the injury is not
compound or severely comminuted.

Immobilization:

Tubigrip and a short period of non-weight bearing on crutches will

be sufficient management in most cases with mild symptoms

Zimmer splint is an alternative option for those with moderate

symptoms.

Plaster immobilization is not usually required, unless symptoms

are severe.

Disposition:

Orthopedic referral will be required for:

Severely displaced and/ or comminuted fractures

 Compound fractures

Fractures associated with peroneal nerve injury

Maisonneuve fractures which are considered unstable ankle joint injuries and
require ORIF.
Appendix 1 Maisonneuve injury:

Significant ankle injury in a 33 year old male. The tibia has a spiral fracture. The knee
pain of the patient was a less prominent feature of the presentation compared to the
patients ankle pain. The knee was also imaged, as shown below.
X-rays of the knee demonstrated a classic Maisonneuve injury pattern, with a spiral
fracture of the proximal shaft of the fibula. Note the importance as always of obtaining
both A-P and lateral films when examining for bony injury - the fibula fracture is only
apparent on the AP view and cannot be (readily) discerned on the lateral knee images.
The image on the right is an excellent overview of the Maisonneuve injury pattern, as
well as demonstrating the importance of visualizing the entire bone of an injured limb.
References

1. Pitfalls in Orthopedic Radiography Interpretation. Michelle Lin, MD FAAEM

Assistant Clinical Professor of Medicine, UC San Francisco San Francisco
General Hospital Emergency Services 2008.

Dr J. Hayes
Dr S. Smith
Reviewed 1 August 2012.