Posterolateral vs. anterolateral approach for posterolateral tibial plateau fractures: A multicenter cohort with four-year outcomes.

This study aimed to quantify the temporal evolution of multiple organ dysfunction syndrome (MODS) following trauma with secondary sepsis and to validate a rodent-specific MODS scoring system over 6-72 hours. A total of 168 male Sprague-Dawley rats (8 weeks old, SPF grade) were randomly divided into four groups: the normal control group (NC group), limb crush injury group (Fx group), cecal ligation and puncture group (CLP group), and limb crush injury combined with CLP group (Fx+CLP group). A stepwise CLP surgery was performed in the Fx+CLP group 24 hours after closed tibial and fibular fracture surgery to mimic the clinical window of high infection incidence. Five observation time points were set: 6, 12, 24, 48, and 72 hours. Hematological parameters were detected, and tissues of rats were examined histopathologically before a diagnostic scoring system for MODS in experimental animals was constructed. The mortality rate of the Fx+CLP group was 58.33%, significantly higher than in the other groups ( P < 0.01). The levels of white blood cells, interleukin (IL)-6, and IL-10 in the Fx+CLP group, which peaked at 24 hours, were notably higher than those of the CLP group at each time point ( P < 0.01). During the organ-function assessment, the Fx+CLP group started to present with cardiac and hepatic dysfunction 12 hours after the first onset, and pulmonary and renal dysfunction 24 hours after the first onset. The pathological damage to the organs worsened with time. Particularly, the brain tissue pathology suggested that the pathological score of the Fx+CLP group exceeded 2 at 24 hours after the first onset. Moreover, coagulation dysfunction started 12 hours after the first onset. In general, the timing features of organ damage were distinct, and the overall damage was much more severe than in the single-factor damage groups. A consecutive 6- to -72-hour quantitative profile of MODS across six organ systems was established, demonstrating that cardiac and hepatic dysfunction emerged at 12 hours, followed by pulmonary, renal, neurological, and coagulatory failure at 24 hours. The validated MODS score was expected to offer a robust translational tool for timing therapeutic interventions.

BackgroundStress fractures frequently occur in athletes and military personnel due to their rigorous training and are typically treated conservatively with immobilization and rehabilitation. However, a displaced distal third stress fracture of the fibula that requires surgical intervention is a rare occurrence.Case PresentationA 20‐year‐old male military recruit under training for 1 month presented with a week‐long history of pain and swelling in his right ankle and difficulty in walking. A plain radiograph revealed a transverse fracture of the fibula with a minimal displacement, consistent with a Kaeding–Miller type III stress fracture. Although considered low‐risk, the fracture was treated surgically with open reduction and internal fixation using a one‐third tubular plate due to the rigorous demands of military training and the extended recovery time associated with conservative management. Postoperatively, nonweight bearing with structured rehabilitation was done, and the fracture healed early without complications.DiscussionA minimally displaced stress fracture of the distal fibula managed operatively is a rare entity with very limited literature published which poses diagnostic and therapeutic challenges. This case demonstrates that minimally displaced fibular stress fractures can be diagnosed using plain radiographs and may necessitate operative reduction and fixation, especially in high‐demand athletes and military personnel.

Noninvasive light-based measurements have recently been suggested for monitoring fracture healing and for the development of smart implants. The aim of this study was to collect the first exploratory longitudinal in vivo data from human distal fibular fractures. In this prospective observational pilot study, blood flow, oxygen saturation, and relative hemoglobin were noninvasively measured by using combined laser Doppler and white-light spectroscopy at depths of 3 mm and 10 mm. In patients with fibular fractures, measurements were performed at 1-3 days, 2 weeks, 6 weeks, 3 months and 6 months after surgery. Patients with fibular nonunion and healthy control participants underwent a single measurement. Fourteen longitudinal fracture patients, a nonunion patient, and 42 controls were included. In the longitudinal fracture group, oxygen saturation at a depth of 10 mm significantly decreased from baseline to 2 weeks (p < 0.001) and remained at a low plateau significantly below healthy control levels throughout the 6-month period. Blood flow and relative hemoglobin levels did not longitudinally change but remained significantly elevated compared with controls (p < 0.001). A single nonunion case demonstrated a markedly low oxygen saturation value (8.3%) combined with increased blood flow. Fibular fractures treated with plate fixation exhibit a prolonged low-oxygen saturation plateau, in contrast to the rapid recovery observed in tibial shaft fractures, possibly due to differences in anatomy or healing mechanisms. The low oxygen saturation observed in the nonunion requires further investigation, as it may have prognostic potential.

Unstable Danis-Weber B distal fibular fractures require anatomical reduction. However, conventional lateral locking plates (LLP) are frequently associated with soft-tissue irritation, high implant removal rates, and limitations in rotational stability. This study aimed to evaluate whether a low-profile double mini-locking plates (DMLP) provides superior clinical outcomes compared to LLP. This was a retrospective cohort study of 120 patients with unstable Danis-Weber B fractures treated between 2016 and 2020. Patients were divided into DMLP and LLP groups according to the fixation method employed. Associated posterior and medial malleolar fractures were treated as needed. Outcome measures included time to radiographic union, AOFAS ankle-hindfoot scores, complications, and implant removal rates over 36 months. The DMLP group achieved significantly faster radiographic union than the LLP group (12.35 vs. 13.48 weeks, p = 0.032). Functionally, patients treated with DMLP demonstrated significantly higher AOFAS ankle-hindfoot scores from 3 months post-operatively through the final follow-up (p < 0.05). Although the DMLP technique required a longer operative time (p < 0.001), the overall complication rate was significantly lower (5.0% vs. 15.0%, p = 0.049). Notably, implant removal was performed significantly less frequently in the DMLP group (41.7%) than in the LLP group (65.0%) (p = 0.009). DMLP showed accelerated union and superior functional recovery compared to LLP. Although the operative time was longer, the technique appeared to be associated with fewer soft-tissue complications and a lower rate of secondary implant removal. DMLP may serve as a viable alternative for unstable fractures, though prospective studies are needed to confirm these findings.

PurposeGeriatric distal tibia and fibula fractures are typically treated with open reduction and internal fixation (ORIF) or prolonged cast immobilisation. These methods predispose to wound complications and delayed weight-bearing. Percutaneous fixation can offer a stable construct allowing for early weight-bearing while minimising wound complications. This case series details the management and outcomes of patients over 65 with distal tibia and fibula fractures and poor soft tissue envelope treated with percutaneous fixation.MethodsA prospective observational study was conducted at two Victorian orthopaedic units, identifying patients over 65 years of age who underwent percutaneous distal tibia or fibula fracture fixation. Patient selection considered soft tissue quality and overall health. Antegrade tibial intramedullary nails and retrograde percutaneous screws were used. Surgery proceeded without delay for swelling or anticoagulation cessation. Clinical notes and radiographs were analysed for premorbid health, mobility status, injury mechanism and classification, fixation methods, post-operative mobility, and treatment complications.ResultsThe study identified 13 ankles in 11 patients (average age 82) across two sites. Fractures included 4 trimalleolar, 5 bimalleolar, 1 lateral malleolar, and 3 distal tibia and fibula diaphyseal. Three fractures were open. Median time to operation was 3 days. Six patients were allowed immediate weight-bearing as tolerated. Median post-operative stay was 5 days. One deep infection required removal of a suture-button syndesmosis device and two minor wound breakdowns (distant to surgical site) were managed non-operatively with dressings.ConclusionPercutaneous distal tibia and fibula fracture fixation appears to be a viable alternative to ORIF in geriatric patients with poor soft tissue envelope, potentially offering reduced complications and earlier mobilisation.Level of evidenceLevel IV.

BackgroundOpen tibial shaft fractures require timely management of both skeletal instability and soft‐tissue injury. Temporary external fixation is useful for early stabilization, but prolonged retention without progression to definitive fixation may increase the risk of delayed union and other complications. This case illustrates a patient‐driven delay from the preferred staged pathway and subsequent salvage after restoration of mechanical stability and biological support.Case presentationA 40‐year‐old man sustained a Gustilo–Anderson Type II open fracture of the right tibial shaft with an associated fibular fracture following a road traffic accident. He presented approximately 40 min after injury with a clean 2 cm wound over the anteromedial midleg and intact distal neurovascular status. Immediate preoperative radiographs before initial stabilization were unavailable because the case was reviewed retrospectively. After resuscitation and optimization, irrigation, debridement, primary wound closure, drain placement, and monolateral external fixation were performed on November 22, 2024. Serial follow‐up radiographs showed maintained alignment but limited progression toward union. Early conversion to intramedullary nailing was advised, but the patient initially declined further surgery for personal and socioeconomic reasons. On February 12, 2025, the external fixator was removed and intramedullary interlocking nailing with autogenous bone grafting was performed as a salvage procedure. Follow‐up radiographs showed progressive callus formation and solid union at late follow‐up on March 27, 2026. No postoperative wound complication or deep infection occurred.ConclusionsThis case should not be interpreted as supporting delayed conversion as routine practice. Rather, it illustrates a cautionary salvage scenario in which patient‐driven delay disrupted the preferred staged pathway, and union was achieved only after definitive restoration of stability and selective biological support.

The aim of this study is to describe the basic pathoanatomical characteristics of a stable Maisonneuve fracture and mid-term results of its nonoperative treatment. The study included 17 prospectively collected patients with a mean age of 59 years. The postinjury ankle CT had to meet the following criteria: nondisplaced or minimally displaced (up to 1mm) fracture of medial malleolus, medial clear space less than 3mm, nondisplaced or minimally displaced (up to 2mm) fracture of posterior malleolus, anatomical position or minimal malposition of the distal fibula in the fibular notch (widening of the tibiofibular space up to 2mm or external rotation of the distal fibula up to 10°). The average follow-up period was 34 months, the final follow-up included CT examination and functional evaluation based on AOFAS and FAOS scores. A medial malleolus fracture was recorded in 12% cases, a posterior malleolus fracture in 29% patients and a Tillaux-Chaput tubercle fracture in 18% cases. All fractures of the proximal fibula, medial and posterior malleolus healed within 3 months. The position of the distal fibula in the fibular notch did not change in 11 cases compared to the post-injury CT scan, improved slightly in 5 cases, and worsened slightly in 1 case. The average final AOFAS hindfoot score was 96.9 points and the average final FAOS score was 98.7%. A stable form of the Maisonneuve fracture is characterized by no or minimal displacement on CT scans and can be successfully treated nonoperatively.

Tubular versus anatomically contoured low-profile plate fixation of Weber B fibula fractures: A threshold-cost analysis based on rates of hardware removal.

Fracture risk is increased in type 1 (T1D) and type 2 diabetes (T2D). Diabetic neuropathy may contribute to this risk. We examined the association between diabetes and fracture risk, and whether diabetic neuropathy, including possible painless and possible painful neuropathy, was associated with increased risk of fracture. In this population-based case-control study, adults (≥18years) with and without diabetes were identified using Danish health registries. All incident fractures (excluding skull/facial) from 2019 to 2021 were included, and up to three age- and sex-matched controls were selected per case. Diabetes and diabetic neuropathy were defined by ICD and ATC codes; neuropathy was classified as possible painful or painless based on prescriptions for neuropathic pain medications. Associations between diabetes, neuropathy, and fracture risk at different sites were estimated using conditional logistic regression adjusted for confounders. We included 265,405 individuals with incident fractures and 778,466 matched controls. After multivariable adjustment, fracture risk was increased in T1D (OR 1.68, 95% CI 1.61-1.76) but not in T2D (OR 0.93, 95% CI 0.91-0.94). Diabetic neuropathy was independently associated with higher fracture risk (OR 1.47, 95% CI 1.40-1.55), with the highest risk in possible painful neuropathy (OR 1.62, 95% CI 1.50-1.74). The association between diabetic neuropathy and fracture risk appeared stronger in men and younger individuals. Site-specific analyses suggested larger point estimates for lower leg fractures and comparatively smaller estimates for vertebral, hip and lower arm fractures. The effect of neuropathy did not differ between diabetes type. Diabetic neuropathy is an independent risk factor for fracture, with particularly high risk in individuals with possible painful neuropathy, potentially due to increased fall risk and impaired bone quality.

Association of body mass index with lower extremity long bone fracture location.

Fibular non-union occurs at an unknown rate in patients with tibial shaft fractures. The purpose of this study was to assess the rate of fibular non-union in patients with tibial shaft fractures. We also assessed if any factors are associated with the rate of fibular non-union. This was an Institutional Review Board (IRB) approved retrospective cohort study performed at a level one trauma center. We reviewed the collected data on 400 patients that had fibular fractures with associated tibial shaft fractures from June 2012 to June 2021. To meet the inclusion criteria for this study, patients 16 years and older needed a minimum of three months of follow-up and sustained fibular fractures with associated tibial shaft fractures fix with an intramedullary rod. The standard and modified radiographic union scale in tibia (RUST and mRUST) fractures score of 8 was used as the parameter to determine fibular union. The rate of fibular non-union was 21% (84/400). Distal 1/3 fibular fractures had a higher non-union rate (25%, 46/179) than proximal and middle 1/3 fractures (12%, 10/83; 20%, 28/138 respectively) (p = 0.036). Patients that had fibular fixation went on to form a non-union at a rate of 25% (31/121) and patients that did not have fibular fixation went on to form non-union at a rate of 19% (52/279) (p = 0.114). Of the patients that did have fibular fixation, those fixed with intramedullary flexible nail (IMFN) or screw are less likely to form a non-union than those fixed with plates (p = 0.049). This study identified the rate of fibular non-union in patients with associated tibial shaft fractures treated with an intramedullary rod. We also identified that there is an increased risk of non-union when there is fibular fixation with plates and screws versus IMFN. We do not know the clinical implications of this, but it may be a source of pain in patients with healed tibia shaft fractures therefore we believe a prospective randomized controlled study may be warranted.

The use of serratus anterior artery as the pedicle for complex humerus reconstruction with a vascularized fibular graft: Anatomical study and clinical application in a case series.

To compare the short-term outcomes and complications of the poller screw (PS) and the poller K-wire (PW) in distal tibia nailing. In the present study, a retrospective analysis was performed on prospectively collected data, 43 cases were included in the study. 16 patients were included in the PS group and 27 patients in the PW group. Demographic data, fracture union times, RUST scores, alignment in the coronal and sagittal planes, associated fibula fractures and fixation, malunion, and complications were compared. A subgroup analysis was performed according to fibula fixation and the number of distal locking screws. There was no significant difference between PS and PW groups in respect to age, gender, trauma etiology, fracture-joint distance and AO classification of fractures. In the PS group, the operation time and final coronal angulation were significantly higher (operation time: 81.5 ± 15.27 minutes and 72.22 ± 11.79 minutes, respectively, p = 0.031; coronal angulation: 3.12° ± 3.2° and 1.24° ± 1.76°, respectively, p = 0.044). No statistically significant difference was found in terms of fracture healing time and RUST scores. Non-union was observed in one patient in the PS group. There was no significant difference in fracture healing times and RUST scores when subgroup analysis was performed according to fibula fixation and distal locking screw numbers. The PW technique offers significant advantages in terms of surgical efficiency and reduction quality in the coronal plane. Although the risk of wire displacement remains a disadvantage that must be minimised with careful technique, these advantages make PW a preferable alternative to PS for assisting reduction in distal tibial nailing, where PS has disadvantages such as longer operating times and less optimal alignment control. The use of PW instead of PS has no negative effect on fracture union time and also improves alignment and decreases the operative time.

Maisonneuve fractures involve the disruption of the syndesmosis and necessitate surgical intervention. The aim of surgery is to restore fibula length and stabilize the syndesmosis. Classic manual reduction may not achieve fibular lengthening and is strenuous to maintain during syndesmosis fixation. Hence, we report our method of reduction with a distraction technique that provides mechanical advantages. We present a case series of 3 patients with Maisonneuve fractures in which indirect fibular reduction was achieved using a novel distraction technique with instruments. Cases 1 and 2 suffered an isolated high fibular fracture, whereas Case 3 had concomitant ankle fractures. Syndesmosis disruption was confirmed intraoperatively with the Cotton and external rotation tests. All 3 cases underwent dual-suture button fixation of the syndesmosis. To achieve the reduction, a 3-hole plate was applied on the distal fibula fragment with a cortical screw applied over the most proximal hole. Subsequently, a 5 mm Steinmann pin was drilled into the lateral tibia. The entry point of the tibial pin is immediately anterior to the fibula and 2 cm proximal to the applied fibular plate. An edged lamina spreader was used to apply distraction between the plate and the Steinmann pin. Temporary reduction is held with a quadcortical K-wire, followed by suture button fixation through the middle and inferior holes of the fibular plate. Postoperative imaging showed a normal talocrural angle and the fibula dime sign. This technique provides mechanical advantages in strength and stability, maintaining the reduction while freeing the surgeon’s hands to perform syndesmosis fixation. Level of Evidence: Level lV.

Pediatric acute compartment syndrome (PACS) is a challenging condition to diagnose and can result in significant morbidity for children. Our aims were to: (1) determine if overnight observation is warranted in isolated diaphyseal tibial fractures; (2) identify risk factors of PACS. Acutely managed children with isolated tibial diaphyseal fractures +/- fibula fractures from 2012 to 2023 were reviewed. This cohort was cross-referenced with a list of children undergoing fasciotomies. Demographic information and the mechanism of injury were documented. Fractures were classified using the AO-OTA system and measured for translation and angulation. A total of 339 children were included for analysis, of whom 217 children were admitted for overnight observation without the intent to operate and developed PACS at a frequency of 2.8%. We observed that the children who developed PACS in this cohort were older (14.0±1.5 vs. 10.1±4.0y, P=0.015) and had lower sagittal angulation (2.2±2.6 vs. 6.3±7.1 degrees, P=0.03). One hundred twenty-two children were admitted with the intent to operate, and developed PACS at a frequency of 3.3%. Among the children admitted with the intent to operate, those who sustained a high-energy injury developed PACS at a higher rate (9%) than those that sustainied a low-energy injury (0%) (P=0.017). All fasciotomies were performed at the time of initial treatment. PACS in children is fortunately an uncommon condition, providing the clinician with an opportunity to manage their tibial diaphyseal fractures without an overnight observation, as long as appropriate nonoperative management is initiated. At this time, initial displacement or fracture complexity cannot guide the clinician's decision for admission, but future research in a multicenter, prospective fashion could hold the key to better understand which predictor is most important related to the development of pediatric acute compartment syndrome in tibial diaphyseal fractures. Level III.

Pediatric horizontal distal metaphyseal tibial fractures are relatively uncommon injuries. While nonoperative treatment remains the standard of care for most cases, certain fracture patterns may carry a higher risk of treatment failure, and optimal treatment strategies are still unclear. The aim of this study was to investigate the frequency, anatomical location of these fractures within the metaphysis, and risk factors associated with treatment failure in nonoperative management. A retrospective, registry-based cohort study was conducted to evaluate treatment success in 86 consecutive pediatric patients with distal metaphyseal horizontal tibial fractures between 2014 and 2023. Demographic, clinical, and radiographic data were analyzed. Logistic regression analysis was performed to identify independent predictors of nonoperative treatment failure. Nonoperative treatment failure was defined as the requirement for cast wedging, re-reduction, or surgical intervention due to loss of reduction or coronal angulation greater than 10° observed on final follow-up radiographs. Of the 86 patients included, 70 (81%) were initially treated non-operatively, while 16 (19%) underwent primary surgical fixation. The overall failure rate in the nonoperative group was 35.3% (25/70). Multivariable logistic regression identified 3 independent predictors of treatment failure: age >11 years (adjusted odds ratio [OR], 10.1; 95% confidence interval [CI], 1.3-81.7; p = 0.030), the presence of a complete fibular fracture (adjusted OR, 6.1; 95% CI, 1.2-30.1; p = 0.027), and initial coronal angulation >10° (adjusted OR, 4.9; 95% CI, 1.1-23.0; p = 0.042). The complication rate was significantly higher in the operative group compared to the nonoperative group (18.3% vs. 4.3%; relative risk, 4.4; 95%CI 1.0-19.7, p = 0.042). Nonoperative treatment remains an effective approach for the majority of pediatric horizontal distal metaphyseal tibial fractures. However, patients with older age, concomitant complete fibular fractures, or marked initial angulation may benefit from early surgical intervention to mitigate the risk of treatment failure. IV.

Lower extremity fractures are relatively common in winter sports. This retrospective descriptive study evaluated the demographics, injury mechanisms, and environmental factors associated with lower leg fractures (below the knee, excluding tibial plateau and fibular head fractures) among patients treated at a Colorado clinic during the 2012/13 to 2016/17 ski seasons. The chart review confirmed diagnoses and assessed associated factors. A total of 346 lower leg, ankle, and/or foot fractures were identified, representing 5.4% of all visits. The average patient age was 33.1 years (range 4-74), and 60.7% were men. Most injuries were ski-related (84.7%). The majority of fractures were sustained among skiers and snowboarders who self-identified as a beginner or an intermediate skill level (64.8%), on easy or intermediate runs (64.9%). The most common injuries were complete tibia/fibula fractures (36.4%), isolated tibia fractures (28.3%), and lateral malleolus fractures (26.9%). Of the complete tibia/fibula fractures, 57.0% were "boot-top" fractures. Danis-Weber B was the most frequent type of lateral malleolus fracture (73.6%). Only 12 foot fractures were recorded. In conclusion, lower leg fractures were more common in skiers than snowboarders and in men than women. Most fractures occurred on mild-to-moderate runs, with lower risk in older individuals. Tibia/fibula fractures were most common, followed by lateral malleolus fractures.

Intramedullary pinning of concomitant fibular shaft fractures prevents postoperative tibial shaft malalignment without increasing soft tissue complications.

Weber B ankle fractures with medial clear space (MCS) widening on stress radiographs are unstable injuries that may require surgical stabilization. Initial emergency department management varies, with patients receiving a cast or splint after reduction, although concerns for soft tissue complications often limit cast use. It remains unclear whether splint or cast immobilization affects clinical or radiographic outcomes. We retrospectively reviewed 295 patients treated for closed Weber B ankle fractures between January 1, 2017, and February 15, 2025; among them, 96 were determined to have an unstable pattern based on MCS widening on stress radiographs. Inclusion criteria were age ≥18 years, isolated fibular fracture with MCS widening indicating deltoid incompetence, and ankle radiographs at initial, postreduction, and follow-up time points. Patients with bimalleolar or trimalleolar fractures were excluded. We compared MCS values, surgical rates, reduction attempts, and complications across initial immobilization types. Postreduction MCS was significantly smaller in the cast group compared to the splint group (2.79 ± 0.50 vs 3.41 ± 0.83 mm, P < .01). MCS at follow-up remained lower in the cast group and below the 4-mm threshold commonly used to guide surgical decision making (2.73 ± 0.54 vs 4.14 ± 1.10 mm, P < .01). A greater proportion of casted patients maintained reduction at follow-up (n = 72 vs 19, P = .04), reinforcing the association between initial casting and radiographic stability. There were no statistically significant differences in surgical or complication rates between groups. Initial immobilization with a cast in unstable Weber B ankle fractures was associated with improved postreduction and follow-up radiographic alignment measured by MCS. The absence of increased complication rates among cast patients indicates that the superior radiographic stability with casting is not offset by increased complications, although the study may have been underpowered to detect a difference in safety profiles. Future prospective studies can inform the development of standardized immobilization protocols for unstable Weber B fractures. Level III, retrospective comparative study.