Proximal Fibular Fracture Research Articles

Efficacy of Integrated Korean Medicine Treatment Including Motion-Style Acupuncture Treatment for L1 Burst Fracture and Bilateral Femoral Condyle, Proximal Tibial, and Proximal Fibular Comminuted Fractures: A Case Report

Efficacy of Integrated Korean Medicine Treatment Including Motion-Style Acupuncture Treatment for L1 Burst Fracture and Bilateral Femoral Condyle, Proximal Tibial, and Proximal Fibular Comminuted Fractures: A Case Report

Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up.

Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

Case Report: Effectiveness of physiotherapy rehabilitation in a patient with compound grade IIIC proximal third tibia fracture along with vascular injury

The proximal metaphyseal region of the bone is thought to be the location of fractures of the proximal tibia. The surgical management of proximal tibial shaft fractures and high-energy bicondylar tibial plateau fractures is still challenging . Supra-cutaneous plating, also known as a locking compression plate, has been promoted as a crucial technique in the management of challenging reconstructive scenarios since it has shown to be adjustable, concealed, and well-accepted by patients. Physical therapy rehabilitation is critically necessary for a full recovery from a range of orthopaedic issues. Physical therapy rehabilitation is a vital step in the healing process for patients with lower limb fractures. In our study , we rehabilitated a patient with Compound grade IIIC proximal third tibia fracture right side managed with Closed reduction external fixator application and vascular repair along with proximal fibula fracture. Through this study, we developed a physiotherapy rehabilitation protocol that was very helpful for these patients, produced positive results, and served to enhance the patient's quality of life.

Effect of Schatzker type VI tibial plateau fractures combined with a proximal fibular and/or posterolateral joint facet fracture on early postoperative functional recovery

PurposeThe objective of this study was to investigate the effect of proximal fibular and/or posterolateral joint facet (PJF) fractures on early functional recovery after Schatzker type VI tibial plateau fractures (TPFs).MethodsSeventy-nine patients with Schatzker type VI TPFs sustained from November 2016 to February 2021 were divided into three groups according to the integrity of the proximal fibula and PJF (groups A, B, and C). Details including demographics, duration of surgery, and complications were recorded. The Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) score, Hospital for Special Surgery (HSS) score, lateral knee pain and lateral hamstring tightness were ascertained at the final follow-up. The HSS and WOMAC scores have high reliability in evaluating knee function and osteoarthritis.ResultsThere was a significant difference in the HSS score between groups A and C (P < 0.001) and between groups B and C (P = 0.036). The hospital stay was significantly different between groups A and C (P = 0.038) and between groups B and C (P = 0.013). There was a significant difference in lateral knee pain and lateral hamstring tightness between groups A and C (P < 0.001) and between groups B and C (P < 0.001).ConclusionOur study demonstrates that proximal fibular and PJF fractures do not increase the time from injury to surgery, the incidence of complications, or the duration of surgery for Schatzker type VI TPFs. However, fractures of the proximal fibula significantly increase the hospital stay, reduce knee function, and cause lateral knee pain and lateral hamstring tightness. Combined proximal fibular fracture is more decisive than PJF involvement for prognosis.

Do associated proximal fibula fractures help predict the severity of tibial plateau fractures?

PurposeProximal fibula fractures are often associated with tibial plateau fractures, but their relationship is poorly characterized. The purpose of this study was to better define the relationship between tibial plateau injury severity and presence of associated soft tissue injuries.MethodsA retrospective review was performed on all operatively treated tibial plateau fractures at a Level 1 trauma center over a 5-year period. Patient demographics, injury radiographs, CT scans, operative reports and follow-up were reviewed.ResultsQueried tibial plateau fractures from 2014 to 2019 totaled 217 fractures in 215 patients. Fifty-two percent were classified as AO/OTA 41B and 48% were AO/OTA 41C. Thirty-nine percent had an associated proximal fibula fracture. The presence of a proximal fibula fracture had significant correlation with AO/OTA 41C fractures, as compared with AO/OTA 41B fractures (chi-square, p < 0.001). Of the patients with a lateral split depression type tibial plateau fracture, the presence of a proximal fibula fracture was associated with more articular comminution, measured by number of articular fragments (mean = 4.0 vs. 2.9 articular fragments, p = 0.004). There was also a higher rate of meniscal injury in patients with proximal fibula fractures (37% vs. 20%, p = 0.003).ConclusionsThere was a significant relationship between the higher energy tibial plateau fracture type (AO/OTA 41C) and the presence of an associated proximal fibula fracture. The presence of a proximal fibula fracture with a tibial plateau fracture is an indicator of a higher energy injury and a higher likelihood of meniscal injury.

Simulation-based prediction of bone healing and treatment recommendations for lower leg fractures: Effects of motion, weight-bearing and fibular mechanics.

Despite recent experimental and clinical progress in the treatment of tibial and fibular fractures, in clinical practice rates of delayed bone healing and non-union remain high. The aim of this study was to simulate and compare different mechanical conditions after lower leg fractures to assess the effects of postoperative motion, weight-bearing restrictions and fibular mechanics on the strain distribution and the clinical course. Based on the computed tomography (CT) data set of a real clinical case with a distal diaphyseal tibial fracture, a proximal and a distal fibular fracture, finite element simulations were run. Early postoperative motion data, recorded via an inertial measuring unit system and pressure insoles were recorded and processed to study strain. The simulations were used to compute interfragmentary strain and the von Mises stress distribution of the intramedullary nail for different treatments of the fibula, as well as several walking velocities (1.0km/h; 1.5km/h; 2.0km/h) and levels of weight-bearing restriction. The simulation of the real treatment was compared to the clinical course. The results show that a high postoperative walking speed was associated with higher loads in the fracture zone. In addition, a larger number of areas in the fracture gap with forces that exceeded beneficial mechanical properties longer was observed. Moreover, the simulations showed that surgical treatment of the distal fibular fracture had an impact on the healing course, whereas the proximal fibular fracture barely mattered. Weight-bearing restrictions were beneficial in reducing excessive mechanical conditions, while it is known that it is difficult for patients to adhere to partial weight-bearing recommendations. In conclusion, it is likely that motion, weight bearing and fibular mechanics influence the biomechanical milieu in the fracture gap. Simulations may improve decisions on the choice and location of surgical implants, as well as give recommendations for loading in the postoperative course of the individual patient.

Investigation of the Characteristics and Mechanism of Interosseous Membrane Injuries in Typical Maisonneuve Fracture

Previous studies on the mechanism and scope of interosseous membrane injury in Maisonneuve fractures have been inconsistent. In order to better guide clinical treatment, the characteristics and mechanism of interosseous membrane injuries and proximal 1/3 fibular fracture in typical Maisonneuve fracture were investigated. The study comprised 15 patients between January 2019 and June 2021 with Maisonneuve fracture. All patients received X-ray and MRI examination of the calf and ankle joint, and CT scanning of the ankle joint. The injuries of medial structure, inferior tibiofibular syndesmosis, fibula, posterior malleolus, and interosseous membrane were evaluated. MR images of the calf showed that the injury of interosseous membrane (IOM) was from the syndesmosis to the proximal fibular fracture site in two patients, with a range of 32.3 and 29.8 cm, respectively. In the other 13 patients, the IOM rupture was not only confined to the distal third of the calf, but also close to the fibula fracture, and the IOM was intact between the two fracture sites. The range of distal IOM rupture was 3.7-12.2cm, with an average of 8.06 ± 2.35 cm. The proximal IOM was completely ruptured from the fibular side at the site of the fibular fracture and the range was 4.1-9.1 (average: 6.75 ± 1.64) cm. The average length of the integrate middle segment of the IOM was 14.55 ± 4.11 (5.6-20.3) cm. MR images of the calf also showed partial rupture of the posterior tibial muscle at the ending point on the fibula in 15 cases, partial rupture of soleus muscle and flexor hallucis longus in seven cases. The rupture of the IOM was caused by a combination of abduction and external rotation violence. It was manifested in two forms, most of which was not only distal end but also near fibular fracture site ruptures with the middle part intact, and a few were ruptures of the IOM from the ankle to the near fibular fracture site. The tibialis posterior muscle may be related to the location of the fibular fracture.

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.

A Case Series of Bosworth Fracture-Dislocations and Review of 129 Reported Cases.

Bosworth fracture dislocations of the ankle are rare injuries of the ankle caused by extreme external rotation of the supinated foot where the proximal fibula fracture fragment is posteriorly dislocated and entrapped behind the posterior-lateral ridge of the tibia. This case series aims to document three such cases treated in our institution over a nine year period. We also provide a review of 129 cases in the existing literature. Medical records and relevant radiographs for each patient were analysed and collected from the time of presentation till the point of latest follow-up. During each clinic visit, all physical exam findings as well as all complications were recorded. The American Foot and Ankle Society (AOFAS) Hindfoot score was also tabulated for each patient at the point of latest review. Closed reduction was unsuccessful in all three patients, and all required open reduction. One patient had an uncomplicated recovery whilst the remaining two suffered significant soft tissue complications. One patient suffered severe soft tissue swelling preventing primary closure at the time of surgery, whilst another suffered post-operative wound dehiscence and infection. Eventually all fractures healed, and all three patients obtained satisfactory AOFAS scores. The diagnosis of Bosworth fracture dislocations of the ankle is often delayed or missed, due to its rare occurrence. Closed reduction is often unsuccessful, and early open reduction is required to avoid poor clinical outcomes due to severe soft tissue damage or even compartment syndrome.

Surgical Fixation of Maisonneuve Fractures with a Screw Suture Fixation Device: Results of 10 Cases

Category: Trauma; Ankle; Sports Introduction/Purpose: Maisonneuve fractures consist of a fracture of the fibula in the proximal third with associated syndesmotic injury. Surgical management generally involves restoration of fibula length, reduction of the syndesmosis, and stabilization of the syndesmosis. Flexible fixation devices have gained popularity for syndesmotic fixation over the last several years. Current flexible fixation devices are not reliable for fixation of length unstable patterns of injury, like the Maisonneuve fracture. The purpose of the study was to evaluate the results of a new screw- suture syndesmotic device providing aperture fixation of the syndesmosis for fixation of Maisonneuve fractures. Methods: 10 consecutive patients with Maisonneuve injuries were treated with indirect restoration of fibula length, open reduction of the syndesmosis, and stabilization of the syndesmosis with the screw suture device. Talocrural angle and medial clear space was measured and recorded at time of injury, post operatively and 6 months. Rate of hardware removal was recorded.***2 patients are 2 months short of 6 months. both have healed their proximal fibula fractures so no changes to data are anticipated *** Results: There were 5 males and 5 females. 5 patients slipped on ice, 4 patients fell on uneven walking surfaces, 1 patient was in a motorcycle accident. 2 patients had associated posterior malleolus fractures, 1 was fixed with a posterior plate. 1 patient had a medial malleolus fracture repaired with 2 screws. 9 devices were placed independently. 1 device was inserted through a 4 hole 1/3 tubular plate. Average time to surgery was 12.3 days (range 5-24 days). Talocrural angles averaged 8.92 (4.8-14.5mm) on injury films, 13.8mm (10.6-17mm) post operatively and 13.5mm (10.6-16.6) at 6 months. Medial clear space measurement averaged 5.68mm (2-10mm) on injury films, 2.06mm (1.9-2.3mm) post operatively and 2.1mm (2-2.3mm) at 6 months. No devices required removal during the study period. Conclusion: The screw-suture device provided length stable fixation for treatment of Maisonneuve fracture patterns.

Proximal Fibular Fracture in Competitive Youth Baseball Player

Proximal Fibular Fracture in Competitive Youth Baseball Player

Flexion Tibial Plateau Fractures: 3-dimensional CT Simulation-based Subclassification by Injury Pattern.

ObjectiveTo identify different injury patterns of flexion tibial plateau fractures (FTPFs) with 3D CT simulation technology. The association between these hypothesized injury patterns and concomitant injuries was also investigated.MethodsThe tibial plateau fracture cases of 297 patients consecutively treated at our trauma center from August 2016 to December 2018 were reviewed retrospectively. A total of 108 patients with FTPFs were enrolled. 3D CT simulation technology was used to reconstruct the position of the knee joint at the time of tibial plateau fracture. The 3D segments for the tibia and femur were created separately, the tibial 3D segment was aligned with the articular surface of the femoral condyle, and then the corresponding injury patterns were deduced. The magnitudes of translation and rotation incurred after the segments were repositioned were calculated by Mimics software. The associations between the hypothesized injury patterns and concomitant injuries were compared.ResultsFTPFs were classified into two groups according to the fracture region: unicondylar FTPFs (type I) and bicondylar FTPFs (type II). According to the injury patterns simulated in this study, these two types of FTPFs were further subclassified into five subgroups. Type I FTPFs were categorized into two subtypes based on the degree of rotation in the coronal plane (varus < 0°; valgus > 0°): pure flexion‐varus fractures (type IA, −10.23° ± 2.11°, 3.7%, 4/108) and pure flexion‐valgus fractures (type IB, 11.54° ± 2.63°, 26.9%, 29/108). Type II FTPFs were divided into three subgroups based on the degree of rotation in the axial plane (internal rotation >10°; flexion‐neutral −10° to 10°; external rotation <−10°): flexion‐neutral fractures (type IIA, 2.01° ± 3.43°, 13.0%, 14/108), flexion‐internal rotation fractures (type IIB, 23.66° ± 6.17°, 35.2%, 38/108) and flexion‐external rotation fractures (type IIC, −16.23° ± 4.27°, 21.3%, 23/108). The incidence of posterolateral quadrant collapse fractures among type IIB fractures was significantly increased relative to that of type IIC fractures (P < 0.001). The incidence of posterolateral quadrant split fractures, anterolateral quadrant fractures and proximal fibular fractures among type IIC fractures was significantly higher than that among type IIB fractures (P < 0.001). The number of these concomitant injuries significantly differed between type IIB and type IIC fractures (P < 0.001).Conclusion3D CT simulation‐based subclassification according to the pattern of injury can help surgeons better understand FTPFs and select an appropriate treatment strategy.

Different patterns of tibial plateau fractures associated with hyperextension injuries of the knee with or without varus/valgus component.

This study aims to introduce a morphological classification of hyperextension tibial plateau fractures based on CT scans and to reveal the correlation between the anterior compression and posterior tension fractures.From January 2015 to January 2019, 37 patients with hyperextension tibial plateau fractures were studied retrospectively. Based on this classification, the fractures were divided into 2 groups: group A had anterolateral or anteromedial compression fractures while group B had both. Three observers classified the fractures and recorded the morphology and incidences of posterior plateau fractures and proximal fibular fractures.All 37 fractures were allocated to group A (n = 15; 40%) and B (n = 22; 60%). Of the posterior tibial plateau fractures, 10 (27%) fractures were defined as partial and 27 (73%) as total. Of the 37 fractures, 18 (49%) proximal fibular avulsion fractures were observed. There was a significant difference between groups A and B regarding the incidence of total posterior tibial plateau fractures (P < .05). However, there was no significant difference between the incidence of proximal fibular avulsion fractures in the 2 groups or the combined and non-combined type fractures in group B (P > .05).Hyperextension tibial plateau fractures with a decreased posterior slope angle always involve both the anteromedial and anterolateral plateaus. This CT-based classification may improve the understanding of fracture features and is helpful for planning treatment.

A New Three-Dimensional Classification of Proximal Tibiofibular Fractures: A Multicenter Study.

ObjectivesTo propose an updated definition of proximal tibia and fibula fracture (PTFF) and establish a three‐dimensional (3D) structure‐based classification of PTFF.MethodsIn total, 1358 adult patients (837 males and 521 females; 43.61 ± 15.13 years， 1364 affected knees) who were diagnosed with PTFF at the departments of orthopaedic surgery of four hospitals from January 2010 to December 2019 were enrolled. The new classification of PTFF, termed Wu classification, included three parts: classification of columns in the horizontal plane, regions in the frontal plane, and segments in the sagittal plane. All PTFFs were classified according to Schatzker, Luo, and Wu classification systems. Additionally, the incidence and characteristics of PTFFs were analyzed.ResultsThe major internal structural fractures of PTFF were tibial plateau fracture (TPF) only (725, 53.15%), TPF and proximal fibular fracture (274, 20.09%), and isolated avulsion fracture of the posterior cruciate ligament (PCL) (189, 13.86%). Approximately a quarter of PTFF cases could not be classified using Schatzker or Luo classifications, but all PTFF cases could be classified using Wu classification. The most frequent PTFFs included all four columns in region IV, segment 2 (235, 17.23%); the posterolateral and posteromedial columns in region II, segment 2 (191, 14.00%); and the lateral and posterolateral columns in region IV, segment 2 (136, 9.97%). Isolated avulsion fracture of the anterior cruciate ligament (ACL) was categorized as three injury types, most of which involved the lateral and medial columns in region II, segment 1 (40/63, 64%). More than 97% of cases of isolated fractures of the PCL involved the posterolateral and posteromedial columns in region II, segment 2. The most frequent combined avulsion fracture of the ACL and PCL included all four columns in region II, segment 2 (18/24, 75%). All of the isolated avulsion fractures of the ACL were located in segment 1, and all those of the PCL in segment 2. The most common type of isolated proximal fibular fracture involved the posterolateral column in region III, segment 2 (23/26, 88%). The most frequent combined TPF and proximal fibular fracture involved all four columns in region IV, segment 2 (107/274, 39.05%).ConclusionsAll cases of PTFF could be classified by the new 3D Wu classification which should be beneficial for clinical diagnosis, guidance of treatment, statistical analysis, academic communication, and prognosis, and the most frequent PTFF involved all four columns in region IV, segment 2.

"Double Maisonneuve fracture": an unknown fracture pattern.

The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism. The study comprised 11 patients, 5 men and 6 women, with the mean age of 57years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings. The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients. Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.

Classification and Treatment Strategies of Concomitant Fibular Column Injuries in Tibial Plateau Fractures.

Background About 1/3 of tibial plateau fractures are associated with proximal fibula fractures, but most proximal fibula fractures are often ignored. The aim of this study was to precisely explain the classification and treatment strategies of six injury types of the fibular column associated with tibial plateau fractures. Methods Patients with ipsilateral proximal fibula and tibial plateau fractures treated in our hospital were retrospectively reviewed from Aug 2007 to Mar 2020. Two experienced surgeons and two radiologists divided fibular column injury into 6 injury types according to the AO classification and four-column nine-segment classification. The treatment scheme (surgically treated or conservatively treated) was also recorded. Results In total, 355 proximal fibula fractures were included. Type 2 fibular head fracture was the most common type of injury in 122, and the segregate of superior tibiofibular syndesmosis was the rarest type in 3. In avulsion injury proximal of fibular pattern, the proportion of patients who need surgical intervention is the highest. Conclusions Six injury types in the four-column nine-segment classification covered all types of bony and soft tissue injuries of the fibular column and concisely explained the injury mechanism. The classification is helpful for the precise judgement and decision-making of the concomitant fibular column injuries in tibial plateau fractures.

Delayed fracture union in a case of vitamin D dependent rickets associated with pulmonary tuberculosis - a case report

&lt;p&gt;Rickets is a defect of bone mineralization caused by vitamin D deficiency, seen most significantly at growth plates that result in radiological bony abnormalities like metaphyseal flaring and cupping, physeal widening with focal and generalised osteomalacia.&lt;strong&gt; &lt;/strong&gt;Here we present a rare case of 7 years old male, a case of vitamin D3 deficiency rickets in a known case of multi drug resistant pulmonary tuberculosis. The patient had suffered left proximal fibular fracture following trivial fall 1.5 month back and had delayed bony union leading to difficulty in walking and pain. The patient was treated with oral vitamin D supplementation. In vitamin D deficiency rickets, there is decreased bone mineralization leading to weak bones and delayed fracture healing in children. Low serum vitamin D levels also caused decreased immunity with increased susceptibility to respiratory infections like pulmonary tuberculosis. Appropriate treatment with injectable or oral vitamin D3 with adequate exposure of sunlight and proper nutrition is the best modality of treatment.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Preventable iatrogenic cause of foot-drop in knee injuries with literature review

PurposeCommon peroneal nerve palsy is quite disabling and every effort should be made to prevent its injury during the treatment. MethodsWe retrospectively reviewed the prospectively collected data of 7 cases of tibial plateau fractures in association with proximal fibula fracture from January 2019 to September 2019 who presented to emergency room of our hospital. ResultsIn addition to fibular neck fracture, the first case had type 6 tibial plateau displaced fracture and the second case had displaced acetabular fracture with instability of knee with tibial tuberosity avulsion. common peroneal nerve palsy developed following application of distal tibial skeletal traction in both the cases. Other 6 such cases remained neurologically intact as traction was not applied to them. ConclusionSuch iatrogenic complication could have been prevented if the injury pattern of "concomitant medial and lateral columns" of the proximal leg is kept in mind by the treating surgeon before applying skeletal traction.

P109 Sherlock Holmes in Clinical Practice: The Deduction of the Pattern and Mechanism of Injury in Ankle Fractures Using Lauge-Hansen System

IntroductionAnkle fractures are among the commonest fractures in adults and as population ages, the incidence is also increasing. It is crucial to ascertain the mechanism of injury of an ankle fracture as it determines the management plan. The diagnosis and management of ankle fractures are usually relatively straightforward but they are not always the case. Most patients are unable to recall the exact mechanism of injury due to the instantaneous nature of incident. We herein describe a case report of a patient who sustained an ankle fracture following a fall but was unable to recall the exact mechanisms of injury. This case report addresses the importance of recognising Maisonneuve fractures and how Lauge-Hansen Classification system might be useful in diagnosing and making management plans for ankle fractures.Case ReportA 30-year-old male self-presented to the Emergency Department in a wheelchair following a fall. He tripped down the last four steps of stairs the night before, sustaining a right ankle injury as a result. He has been unable to weight-bear since. Elevation and application of ice packs have showed limited effect. Patient was unable to recall the exact mechanism of injury. On examination, the right ankle was swollen and there were bruises around the medial malleolus. Upon palpation, he complained of bony tenderness around lateral and medial malleoli. No other injury was found and patient was neurovascularly intact. A referral was made to the Orthopaedics team and further orthopaedic examinations revealed tenderness and crepitus upon palpation over the proximal fibula. Full lower leg X-rays was ordered to look for possible proximal fibula fracture. A diagnosis of closed, Maisonneuve (Weber C)/trimalleolar fracture of the right ankle was made.A CT-scan of the right ankle was requested to determine the involvement of joint surface to aid surgical planning. Both CT-scan and ankle X-rays showed disrupted syndesmosis. Disrupted syndesmosis is most commonly associated with Weber C fractures as shown in this case. Since the fibular fracture is greater than 4.5cm away from the tibial plafond, syndesmosis fixation is required. In Maisonneuve fractures, syndesmotic screws can be used to achieve anatomical reduction and ankle stability. This patient was scheduled for an ORIF surgery.DiscussionsBased on the findings of medial and posterior malleoli fractures from the ankle X-rays, we can deduce that the patient has most likely sustained a complete Pronation-External Rotation (PER) injury. A Maisonneuve fracture was almost missed initially due to distracting injuries and not obtaining full lower leg X-rays. However, based on Lauge-Hansen Classification, we know that it is highly unlikely to have a posterior malleolus fracture (Stage 4) without any fibular fracture (Stage 3). Hence, a full-fibula X-ray was ordered to look for proximal fibula fracture and the X-rays revealed a spiral fracture at the proximal fibula (Maisonneuve fracture). The injury force was transmitted along the interosseous membrane and exited at the shaft of proximal fibula, causing a proximal fibular fracture. PER or injury sustained from an internally rotated leg on a planted foot may cause external rotation injury, resulting in a disruption of the ligaments. The syndesmosis, which provides primary support to the ankle, if disrupted, will disrupt the ankle mortise, displacing the fibula laterally, as demonstrated in this case.ConclusionAs demonstrated in this case, some fractures, like the Maisonneuve fracture, can easily be missed. Due to distracting injuries, the chief complain in most cases of Maisonneuve fracture is severe ankle pain instead of the fracture site at proximal fibula. These fractures, if not identified early, can lead to poor prognosis. It is important to consider Maisonneuve fracture in all ankle injuries. A delayed diagnosis can lead to post-traumatic arthritis and pain, leading to loss of function. This case report addresses the importance of recognising easily missed fractures and how Lauge- Hansen Classification system is useful in aiding the diagnosis and management of ankle fracture

The degree of fracture displacement does not affect the risk for concomitant proximal fibular fractures in tibial plateau fractures.

Theproximal fibula plays an important role in the knee joint; however, it has not been given enough attention by surgeons. This study aimed to investigate the risk factors for concomitant proximal fibular fractures in patients with tibial plateau fractures through computed tomography (CT) imaging. From January 2016 to November 2017, patients who underwent percutaneous reduction and internal fixation (PRIF) for tibial plateau fractures ata level 1 trauma centreinstitute were included in this retrospective study. Full materials of CT imaging were obtained for measurements. Schatzker's and a newly proposed classification system were used for the fracture of the tibial plateau and proximal fibula, respectively. Several clinical and radiological characteristics were recorded, and the impact of those variables on fibular fractures was assessed with univariate and multivariate analyses. In total, 174 patients were enrolled in the study with mean age of 45.6±13.1 years. The incidence of combined proximal fibular fracture was 38.3%. Schatzker type VI fracture had the highest rate of fibular fracture (77.4%). High-energy-pattern tibial plateau fractures (p=0.029) and posterolateral joint facet (PJF) involvements (p=0.002) are risk factors for proximal fibular fracture on multivariate analysis. Neither posterolateral column (PLC) involvements nor fracture displacement correlated with proximal fibular fractures. Proximal fibular fractures were commonly seen among patients who sustained tibial plateau fractures. Schatzker type VI fractures had the highest rate of fibular fractures than other fracture types. High-energy fractures and PJF involvements correlated with a higher risk of proximal fibular fractures. A better understanding and awareness of the risk factors for proximal fibular fractures will provide surgeons with comprehensive understanding of tibial plateau fractures.