Surgery is rarely indicated for a small fibular avulsion fracture. Once most of the acute swelling and pain has settled the patient will benefit from physical therapy to work on regaining strength, ankle motion, and balance. After 2-6 weeks the symptoms will usually have settled to the point where patients can begin weight bearing on the ankle, either in a walker boot or an ankle brace. It is helpful to work on very gentle range of motion exercises as the ankle swelling begins to settle. The patient can be transitioned to a walker boot, or ankle brace in the following 1-2 weeks. Immobilization in a cast or splint is common immediately after the initial injury. Rest, ice, elevation, and anti-inflammatory medication can be helpful in the first few days after the injury. Small fibular avulsion fractures can be treated the same as a severe ankle sprain. Both x-ray views are necessary as the fracture may only be visible in one projection. Imaging StudiesĪ simple set of ankle x-ray from the front and from the side (AP and lateral views) is sufficient to make the diagnosis of fibular avulsion fracture. The injury can be quite painful making weight-bearing on the ankle very difficult, but not always impossible. The injury will present similarly to an ankle sprain with swelling and tenderness around the outside bony prominence of the ankle (lateral malleolus). In both situations the ligament ends up being stronger than the fibular bone that it is attached to leading to failure through the bone. Elderly females often have osteoporosis leading to weakening of the bone whereas young males often have very strong ligaments. The highest prevalence of fibular avulsion fractures occurs in elderly females and young adult males. Typically, the avulsed fragment of bone is small and does not enter the ankle joint as it is still attached to the ligament that pulled it off the bone. As a result, the ligaments tear or in some instances a section of the ligament may stay intake and pull off (avulse) a small piece of bone from the end of the fibula. The sudden inward rolling (inversion) of the ankle places excessive strain on the outer ankle ligaments attaching the fibula to various bones in the ankle (talus and calcaneus). The injury is essentially a moderate-severe ankle sprain except that instead of only tearing the outer (lateral) ankle ligaments a small fragment of the prominent outer ankle bone (fibula) is pulled off (avulsed) by the attached ligament. Clinical Presentationįibular avulsion fractures are usually the result of an acute inversion injury to the ankle. Although a fibular avulsion fracture is technically an “ankle fracture” the injury is essentially the equivalent of a moderate-severe ankle sprain and should not be mistaken for a more severe ankle fracture which often does require surgery. The fracture is treated by immobilizing the ankle with a boot or ankle brace with gradual reintroduction of weight bearing over a period of weeks. The diagnosis is made by x-raying the ankle. The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Accessed May 9, 2017.Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. High ankle sprain and syndesmosis injury. 1,2ĭagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA). Patients should be advised that the recovery time for syndesmotic injuries can be twice as long as for a typical ankle sprain and can take 2 to 3 months before return to normal function. Patients are often placed in a non-weight-bearing boot or short leg cast during this time. This includes a non-weight-bearing period for 4 to 6 weeks with progressive weight bearing to tolerance thereafter. If there is no syndesmosis widening, nonoperative treatment is recommended. Medial clear space widening is also the most reliable indicator of a syndesmotic injury.Īny evidence of syndesmosis widening on radiographs is an indication for surgery, which includes syndesmosis screw fixation. Increased medial clear space, measured from the lateral border of the medial malleolus to the medial border of the talus on the mortise view, indicates a deltoid ligament injury. The mortise-view radiograph of the ankle is the most important diagnostic modality to determine whether a significant syndesmotic injury has occurred.
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