Daniel Green, Philip Henman, Mamoun Kremli
Reduction and stabilization of a tibial fracture will frequently reduce the fibula such that fixation is not required.
These fibular fractures may require temporary internal fixation across the physis to produce adequate stability.
Open reduction is necessary if it is not possible to obtain or maintain adequate reduction by closed manipulation.
The following should be considered to minimize secondary damage to the physis:
The K-wire may be inserted retrogradely from the epiphysis into the medullary canal.
The main treatment goals are:
The following equipment is used:
Place the patient in a supine position on a radiolucent table with a block under the heel.
A small lateral approach is typically used with an incision that provides sufficient exposure to visualize and reduce the fracture.
It may be necessary to remove interposed soft tissue and periosteum before reducing the fracture under direct vision, without devitalizing the fracture fragments.
Insert the K-wire from the tip of the fibula retrograde across the physis into the medullary canal.
Bend the K-wire approximately 1 cm from the skin to allow for swelling.
Cut the K-wire and apply a dressing to protect the skin.
A K-wire inserted through the tip of the fibula can be buried if there is adequate soft-tissue coverage.
Release tethered skin around the K-wire by extending the incision.
Alternatively, the K-wire may be placed under the skin with the bent end on the surface of the bone.
Recheck the fracture alignment and implant position clinically and with an image intensifier before anesthesia is reversed.
Confirm stability of the fixation by moving the ankle through a range of dorsi/plantar flexion.
A molded below-knee cast or fixed ankle boot is recommended for a period of 2–6 weeks as the strength of fixation may not provide sufficient stability for unrestricted weight-bearing.
Weight-bearing is encouraged.
Older children may be able to use crutches or a walker.
Patients tend to be more comfortable if the limb is splinted.
Routine pain medication is prescribed for 3–5 days after surgery.
The patient should be examined frequently to exclude neurovascular compromise or evolving compartment syndrome.
Discharge follows local practice and is usually possible within 48 hours.
The first clinical and radiological follow-up is usually undertaken 5–7 days after surgery to check the wound and confirm that reduction has been maintained.
Distal tibial and fibular fractures heal rapidly. Cast and K-wires are typically removed 3–6 weeks after injury, depending on the age and weight of the patient.
Once K-wires and cast are removed, gradual weight-bearing is usually possible.
Patients are encouraged to start range-of-motion exercises. Physiotherapy supervision may be required in some cases but is not mandatory.
Sports and activities that involve running and jumping are not recommended until full recovery of local symptoms.