Fibular Fracture Research Articles

Distal Tibial Interosseous Osteochondroma with Impending Fracture of Fibula, Deformity and Deep Peroneal Nerve Entrapment Neuropathy

Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. We present the case of a 34-year-old woman with an impending fracture, erosion, and weakness of the distal fibula, secondary to an osteochondroma arising from the distal tibia. Early excision of this deforming distal tibial osteochondroma avoided the future risk of pathological fracture of the distal fibula, ankle deformities, and syndesmotic complications.

BIOMECHANICAL STUDY OF MINIMALLY INVASIVE TECHNIQUES IN SURGICAL TREATMENT OF THE TIBIA PROXIMAL EPIMETAPHYSIS FRACTURES.

The aim: Improving efficiency of the tibia proximal epimetaphysis fractures treatment by introducing minimally invasive techniques using the up-to-date metallic constructions. Materials and methods: The study is based on the results of examination and treatment of 119 patients, using arthroscopic technique. The results were evaluated regarding the P. Rasmussen scheme, post-traumatic arthrosis -Kellgren - Lawrence, life quality - «SF-36 Health Status Survey». Results: The offered treatment method provided for the following: good outcomes in BI- 94.1%, satisfactory ones - 5.9%; respectively in BII - 91.7%, 8.3%; ВIII - 92.9%, 7.1%; СI- 87.5%,12.5%; СII - 91.7%, 8.3%; СIII -88.9%, 7.4%, unsatisfactory outcomes - 3.7. Conclusions: The tibia proximal epimetaphysis fractures make up from 8.9% to 11% of all lower leg fractures and up to 87% of the knee joint fractures. Such fractures are accompanied with the knee joint soft tissue injuries in up to 56% of cases. The meniscus injury is diagnosed in 50-94% of the patients; collateral ligament injury: 20% - 83%; anterior cruciate ligament injury : 20% - 69%, femoral muscle ligament injury- up to 47%, joint capsule ruptures - up to 75%, fibular nerve injury - 3% of cases. The treatment fails in 24.2-50% of cases. Operative treatment of such injuries using arthroscopic method provides for mini-invasive intervention character, visualizing and splint reposition control; the opposite compression screw provides for strong fixation.

Редкая травма лодыжки: клинический случай о переломе Мезоннева

Maisonneuve fracture is a rare and complex ankle fracture characterized by a triad of injuries, including a medial malleolar fracture, injury to the inferior tibiofibular syndesmotic complex, and a proximal fibula fracture. This case report presents the case of a 53-year-old female who sustained a Maisonneuve fracture following a fall on the stairs. Physical examination revealed tenderness and swelling in the left ankle, and radiographs confirmed fractures of the medial and posterior malleolus of the left ankle. Despite receiving conservative treatment in the form of a plaster cast, the patient subsequently presented to the hospital with severe pain in the left ankle and proximal fibula. Further imaging examinations confirmed a Maisonneuve fracture accompanied by a proximal fibula fracture, medial malleolar fracture, and posterior malleolar fracture. The patient underwent successful open reduction and internal fixation of the left ankle. This clinical case underscores the significance of a thorough examination and imaging to precisely diagnose rare and complex fractures such as the Maisonneuve fracture, which may be overlooked in clinical practice. Therefore, clinicians should be vigilant of the potential for a Maisonneuve fracture in patients with ankle injuries to ensure timely and appropriate treatment.Key words: Maisonneuve fracture, tibiofibular syndesmotic complex, proximal fibular fracture, rare ankle fracture, clinical case.

Are Rush Nails Still a Good Choice for Fibula Fixation in Ankle Fractures? A Retrospective Study with Five Years Follow-Up.

The aim of this retrospective study is to evaluate if Rush nail fixation still has a role in distal fibular fractures surgery compared with locking plate in terms of fixation quality, complications, functional results and patient satisfaction level. This study included 109 patients (average age 56.05), who had undergone operative treatment for bi- or trimalleolar fractures between 2009 and 2014. The patients were evaluated retrospectively, divided in group A (57 patients treated with Rush nail) and group B (52 patients treated with locking plate). The patients were evaluated at an average 4.9 years of follow-up (SD: 1.01) with Olerud-Molander Ankle Score (OMAS), American Orthopedic Foot and Ankle Society - Ankle-Hindfoot Scale (AOFAS) and Visual Analogue Scale (VAS) for clinical outcomes. X-rays were conducted to assess ankle osteoarthritis using the classification system by Takakura and joint space symmetry using measurements in comparison with contralateral ankles. The groups were homogeneous regarding age and gender. Patients treated with Rush Nail fixation (Group A) showed statistically significant worse clinical results at functional scores (78.1 Group A versus 88.7 Group B at the OMAS (P<0.05); 83.1 Group A versus 90.1 Group B at the AOFAS (P<0.05); higher pain levels in the VAS (3.9 Group A versus 2.4 Group B) and lower satisfaction rates (52.6% Group A versus 73.1% Group B (P<0.05)) in comparison with patients treated with locking plate fixation (Group B). However, infections rate was significantly lower in Group A (1.8%) than in Group B (9.6%) (P<0.05). Radiographic evaluation showed more cases of post-traumatic osteoarthritis in Group A (35.1% Group A versus 15.4% Group B (P<0.05)) and worse results in regards to restoration of joint space symmetry (45.6% Group A versus 73.1% Group B (P<0.05)). Results of current study indicates that even though plating of lateral malleolus in bimalleolar and trimalleolar fractures is superior in fracture reduction quality, early functional recovery, reduced incidence of post-traumatic osteoarthritis and greater patient satisfaction, Rush nail fixation still provides acceptable clinical results with a lower infection rate. Therefore Rush nails could be considered as a valid choice in selected patients with high risk of soft tissue complications or low functional demand.

Distal Fibula Fracture Fixation: comparison between the One Third Tubular plate and Anatomical Contoured Locking plate

Distal Fibula Fracture Fixation: comparison between the One Third Tubular plate and Anatomical Contoured Locking plate

ANALYSIS OF 45,507 SURGICAL TREATMENT OF DISTAL TIBIA AND MALLEOLAR FRACTURES OVER 14 YEARS.

To evaluate the annual incidence and reimbursement value of distal leg joint fractures requiring surgical treatment from 2008 to 2021. A retrospective study was conducted to analyze the complex structured data of high volume and high variability (Big Data), publicly available on the TabNet platform (DATASUS), via software with artificial intelligence. Data from 2008 to 2021 on surgical treatment for malleolar fracture, distal tibia fracture, and isolated fibula fracture were analyzed. From 2008 to 2021, there was an average incidence of 28.8 fractures/105 inhabitants per year, representing 14.62% of all fractures. The total amount paid for hospitalizations due to these fractures was R$ 34,218,014.62 over these 14 years. The incidence of distal leg joint fractures follows the pattern of those recorded in other countries. The adjustment of reimbursement over the years was lower than the accumulated inflation. Level of Evidence II, Economic and Decision Analyses - Developing an Economic or Decision Model.

Lateral talar subluxation (LTS) in SER ankle fractures is more responsive than medial clear space widening: A cadaveric biomechanical study

Category: Ankle; Trauma Introduction/ Purpose: Supination-external rotation (SER) ankle fractures are characterized by posterolateral translation and external rotation. In isolated fibula fracture SER variants, medial soft tissue structure incompetence can be identified with medial clear space (MCS) widening or with lateral talar subluxation (LTS), frequently obtained on stress view imaging. This assessment is a key determination of which patients may require surgical management to restore ankle joint stability. Current radiographic studies demonstrated increased sensitivity and specificity of LTS versus MCS which may be due to increased rotational movement occurring in the direction of the talar displacement. Biomechanical data has not yet been established. The purpose of this study was to investigate MCS and LTS displacements in a cadaveric biomechanical study to confirm this rotational movement principle in a controlled setting. Methods: An open approach was utilized to surgically create an SER isolated fibula fracture in five below-knee cadaveric specimens. Open anteromedial and lateral ankle approaches were created for visualization of the medial and lateral structures, also allowing direct measurement of the MCS and LTS with a ruler. There was no ankle instability prior to injury, MCS and LTS were zero in each specimen prior to experimental model creation. An SER-pattern fibular osteotomy was made with an oscillating saw. The superficial and deep deltoid were then released from the medial malleolus, and the foot was displaced maximally creating an SER-4b variant ankle fracture. The MCS and LTS were then measured. Differences were analyzed using a paired Student’s t-test. Effect size (Cohen’s d) was measured to characterize statistical significance and determine relative importance in the degree of change. Results: There was no underlying ankle stability, deformity, or arthritis in any of the 5 cadaveric ankle specimens. In our simulated SER-4b ankle fractures, the mean MCS widening using medial landmarks was 7.2 mm (+/- 1.3mm). The mean lateral displacement utilizing the LTS landmarks was 11.2mm (+/- 1.3mm). The difference between medial and lateral displacement was found to be statistically significant (p = 0.0067, 95% CI [1.85, 6.15]). Cohen’s d was equal to 3.1 (95% CI [1.24, 4.90]), demonstrating a large effect size, showing the mean to be different by 3 standard deviations. The increase in mean lateral displacement was 43% greater when compared to the mean medial displacement. Conclusion: In this cadaveric study, LTS displacement was significantly greater than MCS widening following simulation of SER type IV ankle fracture injuries. The effect size of 3.1 confirms statistical significance. This data supports that talus external rotation is a significant factor in SER pattern displacement. The rotational moment arm is largest laterally with external rotation, and posterolateral displacement. Our study supports the idea of measuring the LTS radiographically as a marker to assist in surgical decision-making. Further characterization of the displacement pattern of SER injuries will be helpful to assist surgical decision- making in these common ankle injuries.

Comparation of Clinical Outcome of Surgical vs. Conservative Management for Ankle Fracture Weber Type B: A Systematic Review and Meta-analysis

Introduction: An ankle fracture or broken ankle occurs when the distal tibia or fibula, which make up the ankle joint, are fractured or broken. Soft-tissue injuries, especially to the ankle ligaments, are frequently seen. Accurate reduction of the fracture and syndesmosis is crucial in the treatment of ankle fractures in order to promote bone union and enhance patient functional results. While more unstable injuries are typically treated surgically with open reduction and internal fixation (ORIF) utilizing g a variety of techniques, including plates and screws or tightrope, more stable injuries are frequently treated conservatively with close contact casts or braces. There isn’t a recent systematic review in the literature that covers the best choice of treatment for Weber B fractures. Thus, it was essential to perform this study in order to assess the base of evidence about the surgical and non-surgical treatment of Weber B fractures. Method: A systematic review was comparison of clinical outcome between surgical versus conservative for Ankle Fracture Weber type B. in 256 records from various databases. After the process of identification, screening, eligibility, duplication elimination, and exclusion, the remaining 4 studies were included in qualitative and quantitative synthesis. The Review Manager version 5.4 software (RevMan; The Cochrane collaboration Oxford, England) to perform all statistical analyses Discussion: This study reviewed 4 trials with a total of 1208 participants. Of these, 4 trials focused on AO-type-B distal fibula fracture. Overall, all of the studies that reported functional outcomes found no difference between surgical and conservative management. Conclusion: Both surgical and conservative care of displaced or unstable ankle fractures in adults result in similar functional outcomes and are both appropriate treatment methods

Bosworth ankle dislocation fracture - current concept review.

Bosworth fracture (BF) is a rare, but a severe injury to the ankle, characterized by displacement of a fragment of the fractured fibula (mostly of Weber B type) from the tibiofibular incisure to the posterior surface of the distal tibia. In 70% of cases, it is associated with a fracture of the posterior malleolus. This injury is not quite well known, with only 175 cases described in the literature to date. BF requires CT examination, including 3D reconstructions. Closed reduction almost always fails as there is an increased risk of compartment syndrome, mainly after repeated attempts at closed reduction. Therefore, operative treatment is indicated as a standard. The outcome of the operation should be always checked by postoperative CT examination.

Outcome Assessment of Ankle Spanning External Fixator with Limited Internal Fixation for Distal Tibial Extra Articular Fractures

Background: Road traffic accident claims the lives of almost 1.35 million individuals every year. Because of its subcutaneous arrangement, long bones, particularly the tibia, are usually fractured in these accidents. Since the late 1980s, external fixation with moderate interior fixation has increased. Extra-articular distal tibia fractures generally result from complex, high-energy trauma, which frequently includes accompanying fibular fractures and soft tissue injuries. Method: This is a Hospital-based Prospective Interventional type of study, which include 54 patients, all patients were included in the study of the Orthopaedic department of S.M.S. (Sawai Man Singh) Medical College and attached hospitals in Jaipur Rajasthan, India. The most common trauma mode was road traffic accidents between October-2018 to march-2021. Results: External fixation was used on all fifty-four patients, with or without limited internal fixation. Thirty-eight (70%) of the fifty-four fractures were open, while sixteen (third) were closed. After the operation, the fractures healed in an average of 15.5 weeks. Although none of the patients received bone grafting during the initial treatment of the fracture, twelve patients had bone grafting six weeks after the initial treatment. Mazur’s scoring, modified by Teeny and Wiss, was used to score ankle functions. Angulation of more than 5 degrees is a sign of malunion. Conclusion: External fixation with or without limited internal fixation is an additional option for treating extra-articular distal tibial fractures. Open reduction and plate osteosynthesis have similar union rates.

Outcome After Treatment of Distal Fibula Fractures Using One-Third Tubular Plate, Locking Compression Plate or Distal Anatomical Locking Compression Plate

Surgical treatment of lateral distal fibula fractures is associated with high risk of reoperation and complications. The primary aim was to report risks of surgical site infection (SSI) and reoperation ≤1 year after treatment with one-third tubular plate, locking compression plate (LCP) or distal anatomical LCP. Secondary to investigate associations between patient, fracture and operative factors and risk of SSI and reoperation. Retrospectively, we evaluated a consecutive cohort of 588 patients having osteosynthesis of distal fibula with a one-third tubular plate (n=417), LCP (n=115) or distal anatomical LCP plate (n=56) at Bispebjerg Hospital, Denmark from January 2010 to December 2015 with 1-year follow-up. The risk of SSI was 15% (95% confidence interval [CI] 12-18) after treatment with one-third tubular plate, 30% (95% CI 23-39) after LCP and 41% (95% CI 29-54) after distal anatomical LCP. We found a significant association of SSI and LCP (p=.005) and distal anatomical LCP (p < .001). Other factors associated with increased risk of SSI were age>70 years (p < .001), smoking (p=.004), DM (p=.007), surgery time ≥90 minutes (p=.006) and surgery delay of 3-6 days (p=.007). The risk of reoperation ≤1 year was 10% (95% CI 6-11) for one-third tubular plate, 21% (95% CI 14-29) for LCP and 25% (95% CI 16-38) for distal anatomical LCP. We found a significant association between distal anatomical LCP and risk of reoperation (p=.008). The only other risk factor associated with risk of reoperation was surgery delay of more than 7 days (p=.004). We conclude that LCP plate and the distal anatomical LCP plate should only be used after careful considerations.

Effects of the SARS-CoV-2 pandemic on the incidence of surgically treated fractures in Sao Paulo city

Objective: Evaluate the effect of the SARS-CoV-2 pandemic in the two years since it started. Methods: Retrospective study to analyze the complex structured data set of high volume and variability (Big Data) publicly available on the TabNet platform (DATASUS) through artificial intelligence software. The results of foot and ankle fractures, all lower limb fractures, and all body fractures were analyzed comparatively from 2018-2019 to 2020-2021. Result: The isolated fibula fracture suffered the greatest decrease from 2018-2019 to 2020, and the malleolar fracture presented the highest increase in this period. All fractures showed an increase in 2021 compared to 2020. Except for the distal tibial articular and the talar fractures, the length of hospital stay decreased for all other fractures and the malleolar fracture, remaining up to 36% fewer days hospitalized. Conclusion: COVID-19 pandemic initially decreased the incidence of surgically treated fractures in most fracture patterns, but this effect was not maintained in the second year of the pandemic. The length of hospital stay of these patients decreased in the two years of the pandemic compared to 2018-2019. Level of Evidence II; Retrospective Study; Economic and Decision Analyses - Developing an Economic or Decision Model.

Analysis of the callus process in tibia and fibula fractures reduced with osteosynthesis material

Analysis of the callus process in tibia and fibula fractures reduced with osteosynthesis material

Prediction of distal tibial articular extension in tibial shaft fractures: both posterior malleolar fracture and non posterior malleolar fracture intra-articular extension

BackgroundMultiple authors have highlighted the increased incidence of occult posterior malleolar fractures (PMFs) with spiral tibial shaft fractures, although other reported associated risks of intra-articular extension have been limited. The aim of our study is to investigate both PMFs and non-PMFs intra-articular extensions associated with tibial diaphyseal fractures to try to determine any predictive factors.MethodsWe undertook a retrospective review of a prospectively collected database. The inclusion criteria for this study were any patient who had sustained a diaphyseal tibial fracture, who had undergone surgery during the study period and who had also undergone a CT scan in addition to plain radiographs. The study time period for this study was between 01/01/2013 and 9/11/2021.ResultsOut of 764 diaphyseal fractures identified, 442 met the inclusion criteria. A total of 107 patients had PMF extensions (24.21%), and a further 128 patients (28.96%) had intra-articular extensions that were not PMF’s. On multivariate analysis, spiral tibial fracture subtypes of the AO/OTA classification (OR 4.18, p < 0.001) and medial direction of tibial spiral from proximal to distal (OR 4.38, p < 0.001) were both significantly associated with PMF. Regarding intra-articular fractures, multivariate analysis showed significant associations with non-spiral (OR 4.83, p < 0.001) and distal (OR 15.32, p < 0.001) tibial fractures and fibular fractures that were oblique (OR 2.01, p = 0.019) and at the same level as tibia fracture (OR 1.83, p = 0.045) or no fracture of the fibular (OR 7.02, p < 0.001).ConclusionIn our study, distal tibial articular extension occurs in almost half of tibial shaft fractures. There are very few fracture patterns that are not associated with some type of intra-articular extension, and therefore, a low threshold for preoperative CT should be maintained.Level of evidence4.

Retrospective analysis of locked versus non-locked plating of distal fibula fractures

IntroductionUnstable distal fibular fractures have traditionally been treated with open reduction internal fixation using a 1/3 tubular non-locked plate (compression plating). Locked plating is a newer technique that has become more popular despite the lack of clinical data supporting improved outcomes. The cost of locked plating is almost four times that of compression plating. We compared rates of reoperation due to implant failure, infection, and symptomatic device between compression and locked plating in open reduction internal fixation of distal fibular fractures MethodsA retrospective study was performed at a level one trauma center over a ten-year period (2008-2017). Patients who were 18 and older and treated for unstable ankle fractures with locking or non-locking plate were included in this study. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to determine the cause of reoperation. ResultsIn total, 442 patients were identified with 203 in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent device removal with a higher proportion of patients in the non-locked 1/3 tubular plate cohort (11.3% vs. 6.3%, p = 0.059). Statistically significant differences in reasons for reoperation were found for symptomatic implant (78.3% vs. 46.7%, p = 0.045) and infection (8.7% vs 53.3%., p < 0.01). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning (p < 0.01) whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, p < 0.01). ConclusionsBoth compression and locked plate techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer complications of infection. Given that the cost is significantly less, 1/3 tubular plating placed posteriorly may be preferred to decrease the risks of symptomatic implant and infection.

Incidence of growth disturbance after distal tibia physeal fracture in children.

To analyze the growth disturbance after distal tibia physeal fracture in children. Data about children with distal tibia physeal fractures between September 2015 to September 2018 were collected, including age, gender, affected side, Salter-Harris classification, initial maximal displacement, with or without fibula fracture, open or closed reduction, the method of fixation, time to surgery, blood loss, duration of operation, and complications. Patients were placed in the growth disturbance group when leg length discrepancy was equal to or greater than 1.5cm, or when they had more than 5 degrees of varus or valgus deformity. Others were placed in the no-growth disturbance group. A total of 143 patients (96 boys and 47 girls) were enrolled in this study. The length of the follow-up periods averaged 29.34 ± 7.46months (26 to 61months). Among the total of 143 patients, the incidence of growth disturbance was 15.39% (22/143). The no-growth disturbance group consisted of 121 patients (84 boys and 37 girls), with a mean age of 11.50 ± 3.20years, and there were 68, 52, and 1 injuries to the left, right, and bilateral sides, respectively. The average maximal displacement was 5.51 ± 3.18mm, and 27.27% (33/121) of patients also had a fibula fracture. The growth disturbance group contained 22 patients (12 boys and 10 girls) with a mean age of 9.32 ± 3.56years, and there were 12, 10, and 0 injuries on the left, right, and bilateral sides, respectively. The average maximal displacement was 5.77 ± 4.89mm, and 45.45% (10/22) of patients also had a fibula fracture. There was a significant difference in age (p = 0.004) and fibula fracture (p = 0.011) between the two groups. More patients had Salter-Harris types III and IV fractures in the growth disturbance group than in the no-growth disturbance group (p = 0.043). Children with Salter-Harris types III and IV fractures, younger children, and children with fibula fractures all have a higher incidence of growth disturbance after distal tibia physeal fractures. Level III-Prognostic study.

Outcomes of Conservative versus Operative Management in Fracture Shaft Tibia and Fracture Shaft Femur in Pediatric Age Group

Background: Tibia is more often involved in open fractures because of its subcutaneous location. Severe open fractures of tibia are associated with high complication rate and poor long term outcomes. 70% of pediatric tibial fractures are isolated injuries and approximately 30% of pediatric shaft tibia fractures are associated with fibula fracture. AIM: The aim is to study clinical and radiological outcomes of patient with tibial and femoral fractures, who are treated with closed reduction and internal fixation with nailing versus treated conservatively by casting. Material and method: 40 cases with femur or tibia fractures treated with nailing and conservatively between 1st January 2022 to 30thNovember 2022 at rural medical college, loni a rural tertiary care hospital was analyzed retrospectively out of which 16 patients treated conservatively and 4 patients underwent operative management for tibia fractures while 16 patients were treated operatively and 4 patients treated conservatively for femur fractures. Results: Total 40 patients of shaft femur and shaft tibia fractures were treated conservatively with cast application and Closed reduction and internal fixation by elastic nailing. In comparision for simple transverse fracture, we can conclude that in most patients fracture can be treated conservatively to minimize soft tissue damage but only in unacceptable criteria for conservative management we can opt for minimally invasive procedure like TENS nailing. Conclusion: Immobilization time is shorter in surgical group but we have started mobilizing with cast application. It is the only advantage of surgical management which has been given in conservatively managed patients. Outcomes after 3 months.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary “Photodynamic Bone Stabilisation”

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

Occupational and Physical Therapy Rehabilitation Strategies for COVID-19 Related Guillain-Barré Syndrome: A Case Report

<h3>Research Objectives</h3> To describe the occupational and physical therapy strategies used to rehabilitate COVID-19 related Guillain-Barré Syndrome (GBS). <h3>Design</h3> Single patient retrospective case report. <h3>Setting</h3> Long-term acute care hospital located in Wallingford, Connecticut, USA. <h3>Participants</h3> A 61 year old male admitted for physical and occupational therapy rehabilitation following intravenous immunoglobulin treatment for COVID-19 related GBS. The patient gave his written approval for the creation of this case report. <h3>Interventions</h3> Individual occupational and physical therapy sessions, occupational and physical therapy co-treatment sessions, and targeted group therapy sessions focused on leg, arm, and fine motor coordination exercises. <h3>Main Outcome Measures</h3> Manual muscle testing, range-of-motion, grip-strength, Activity Measure for Post-Acute Care, and St. Louis University Mental Status Exam. <h3>Results</h3> Despite the unforeseen complication of a distal right fibula fracture, the patient was successfully discharged directly home 56 days after LTACH admission. The patient discharged with clinically improved ambulation, strength, self-care, and cognition. <h3>Conclusions</h3> This unique case highlights the complex and significant rehabilitation needs a patient may require to regain independence after a diagnosis of COVID-19 associated GBS. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest to disclose.

Indications for retrograde intramedullary screw fixation of the distal fibula: a retrospective cohort series.

Ankle fractures are a common orthopaedic injury that often require surgical fixation. Because the comorbid population in the United States continues to survive longer, it has become routine to treat comorbid patients with unstable ankle fractures. The literature has identified comorbidities known to increase the risk of ankle fracture complications to include age 55 years or older, body mass index >29.9, polytrauma, open fractures, diabetes mellitus, smoking, peripheral neuropathy, and alcohol use. We retrospectively reviewed 37 patients who received retrograde intramedullary screw fixation of the distal fibula, all of whom had preexisting conditions known to increase the rate of postoperative complications. Thirty-seven patients were included in this study, of whom 36 (97.3%) went on to union. Six of 37 patients (16.2%) had complications although only one (2.7%) was due to inadequate fixation. The average time to weight-bearing as tolerated was 57.2 days (15-115 days). Two patients (5.4%) had symptomatic instrumentation requiring removal after union. Two patients (5.4%) had delayed union of the distal fibula, which responded to the use of a bone stimulator. One patient (2.7%) developed a nonunion which led to chronic subluxation of the ankle joint. One patient (2.7%) had a minor medial ankle wound complication that was treated with oral antibiotics and local wound care. Retrograde intramedullary screw fixation of the distal fibula is a viable alternative to plate and screw fixation in patients with unstable ankle fractures who have known risk factors for increased complications. However, not all distal fibula fractures are amenable to this fixation method. Level III retrospective cohort study.