Fibular Fracture

Description[edit | edit source]

Fractures of the tibia and fibula are most common in athletes, especially runners, or non-athletes who suddenly increase their activity level. Many factors appear to contribute to the development of these fractures including changes in athletic training, specific anatomic features, decreased bone density, and diseases.[1] Fractures of the fibula sometimes occur with severe ankle sprains. The fracture can happen anywhere along the fibula. Although the fibula contributes to weight bearing, it bears a minimal proportion of the body weight, with estimates ranging from 5-17%, hence these fractures, while significant, are not as severe as those in bones bearing a greater proportion of body weight..[2]

Clinically Relevant Anatomy[edit | edit source]

The fibula is a is a bone that plays a minimal role in weight bearing, originating just below the lateral tibial plateau and extending distally to form the lateral malleolus. The minimal weight-bearing capacity of the fibula is due to its slender structure and the distribution of force through the leg, with most of the weight being borne by the tibia. The lateral malleolus provides key stability against excessive eversion of the ankle and foot. Proximally, the fibular head is the site of attachment of the lateral collateral ligament of the knee and of the tendon from the biceps femoris. Just below the fibular head the common fibular nerve wraps around the fibular neck before dividing at the proximal fibula into deep and superficial branches.[1]Along the upper and middle lateral border of the fibula, the Peroneal (Fibularis)Longus and brevis muscles originate and provide some soft tissue protection to the fibula from direct contusion.[3] The fibrous attachment between the tibia and fibula, the tibiofibular syndesmosis, prevents displacement of the lateral malleolus. The distal portion of the syndesmosis has thickened fibers to form the distal tibio-fibular ligament. Stability of this ligament allows the ankle to remain stable with external rotation and during the forceful cutting movements required in many sports. Disruption of the syndesmosis (syndesmotic or high ankle sprain) contributes to instability of the tibiotalar joint.[1]

The fibular bone.
The fibularis longus muscle (in red)


Mechanism of Injury[edit | edit source]

Mechanisms of injury for tibia-fibula fractures vary significantly based on the energy involved and can be divided into two main categories:

  • low-energy. These typically include ground level falls and athletic injuries. In these scenarios, the fibula is often impacted by stress or overuse, particularly in activities where repetitive motion or sudden increases in activity occur. These injuries may result in stress fractures or minor breaks in the fibula, often seen in runners or athletes.
  • high-energy. These are associated with more severe trauma such as motor vehicle accidents, pedestrians struck by vehicles, or gunshot wounds. The fibula, in these cases, is subjected to sudden, forceful impacts that can cause more severe fractures. These fractures are often complex and may be accompanied by additional injuries to the surrounding soft tissues and other bones."

Patients may report a history of direct (motor vehicle crash or axial loading) or indirect (twisting) trauma and may complain of pain, swelling, and inability to ambulate with tibia fracture. [4]

Classification[edit | edit source]

Ankle fractures are classified according to the Danis-Weber classification system [5]

  • Type A is a transverse fibular fracture caused by adduction and internal rotation.
  • Type B, is caused by external rotation, it is shown as a short oblique fibular fracture directed mediolaterally upward from the tibial plafond.
  • There are two type C fractures: Type C 1 is an oblique medial-to-lateral fibular fracture which is caused by abduction. Type C 2 fractures result from a combination of abduction and external rotation, producing more extensive syndesmotic injury and a higher fibular fracture.

The Danis-Weber classification system uses the position of the level of the fibular fracture in its relationship to its height at the ankle joint.

  • Type A: fracture below the ankle joint
  • Type B: fracture at the level of the joint, with the tibiofibular ligaments usually intact.
  • Type C: fracture above the joint level which tears the syndesmotic ligaments.
The Danis-Weber classification types.
Fibula Fracture.jpg


Epidemiology/Aetiology[edit | edit source]

Distal fibular fractures represent the majority of ankle fractures. [6] Fibular fractures in younger adults are often caused by trauma, however when compared to fibular fractures of the elderly that usually occur as a result of low energy injuries, the severity of tissue damage is equivalent. [7] Isolated fibular fractures contain the majority of ankle fractures in older women, occurring in approximately 1 to 2 of every 1000 white women each year.[8] Fibular fractures may also occur as the result of repetitive loading and in this case, they are referred to as stress fractures.

Risk factors[edit | edit source]

Bone mass is the key risk factor for fractures of the fibular or tibial shaft in older adults. Factors that reduce bone mass had greater impact than overall health status or other risk factors for falling. [9] Cigarette smoking is another important risk factor for fibular fractures.[10]

Fibular fractures are more common among athletes engaged in sports that involve cutting, particularly those associated with contact or collision, for example American football, soccer and rugby. [11] Participants in downhill winter sports have relatively high rates of fibular fractures. These are more common in snowboarding than skiing, and fracture patterns are different for each. Skiers often fracture the proximal third of the tibia and also the fibula, whereas snowboarders are more likely to sustain isolated fractures of the distal third of the fibula. [12]

Clinical Presentation[edit | edit source]

A fractured fibula usually presents with the following signs and symptoms: [13]

  • pain, swelling and tenderness;
  • inability to bear weight on the injured leg;
  • bleeding and bruising in the leg;
  • visible deformity;
  • numbness and coldness in the foot
  • tenderness to touch.

Diagnostic Procedures[edit | edit source]

Fibular fractures, while often evident from their symptoms, require a thorough and precise diagnostic approach to ensure accurate identification and appropriate treatment planning. Diagnostic procedures for fibular fractures are designed to not only confirm the presence of a fracture but also to determine its specific characteristics, such as location, type, and severity. These procedures are critical in guiding the choice of treatment, whether surgical or conservative, and in predicting the likely outcome and recovery timeline.

The following are key diagnostic tools and methods used in the evaluation of fibular fractures:

  • Physical examination: A thorough examination is conducted including inspection for any noticeable deformities.
  • X-Rays are used to see the fracture and possible bone displacement.
  • MRI Scans provides a more detailed scan and can generate detailed pictures of the interior bones and soft tissues.
  • Bone scans, CT Scans, and other tests may be ordered to make a more precise diagnosis and judge the severity of the fibula fracture.[13]

Differential Diagnosis[edit | edit source]

Accurately diagnosing a fibular fracture involves not only confirming the presence of a fracture but also differentiating it from other conditions that may present with similar symptoms. [14]

Differential diagnosis is a crucial step in this process, as it helps to rule out other potential causes of the patient's symptoms:

  • Acute Compartment Syndrome
  • Tibia Fracture
  • Ankle Fracture
  • Ankle Injury, Soft Tissue
  • Child Abuse
  • Knee Fracture
  • Pediatric Limp
  • Peripheral Vascular Injuries
  • Soft Tissue Knee Injury

Management / Interventions[edit | edit source]

Distal fibular fractures will predominantly require open reduction surgical fixation, [15] however in stable minimally displaced fractures conservative treatment may be followed with excellent results. [16] If the fracture is open, additional management is warranted to reduce the risk of contamination and infection.

Physical Therapy Management[edit | edit source]

After being in a cast or splint for several weeks, most people find that their leg is weak and their joints stiff. Physical therapy is implemented after an individual assessment of the patient. It is important to assess the following:

  • Pain and oedema
  • Range of motion (ROM)
  • Muscle strength
  • Surgical scar tissue
  • Patient ambulation and weight bearing


Physical therapy usually begins with ankle strengthening and mobility exercises. Once the patient is strong enough to put weight on the injured area, walking and stepping exercises are common. Balance is a vital part of regaining the ability to walk unassisted. Wobble board exercises are a great way to work on balance.[13]

According to ORIF fibula fracture post-operative protocol there are 4 phases in rehabilitation of fibular fracture: [17]

Phase 1- Maximum protection (weeks 0 to 6)[edit | edit source]

  • Cast or boot for 6 weeks
  • Elevate the ankle above the heart
  • Non-weight bearing x 6 weeks
  • Multi-plane hip strengthening
  • Core and upper extremity strengthening

Phase 2- Range of motion and early strengthening (weeks 6 to 8)[edit | edit source]

  • Full active and passive pain-free ROM all planes
  • Strong emphasis on restoring full dorsal flexion
  • Isometric and early isotonic ankle exercises
  • Foot intrinsic muscle strengthening
  • Gradual progression to full weight bearing
  • Restoration of normal gait mechanics
  • Bilateral progressing to unilateral squat, step and matrix progression
  • Proprioception training
  • Non-impact cardiovascular work

Phase 3- Progressive strengthening (weeks 8 to 12)[edit | edit source]

  • Restoration of full range of motion all planes
  • Advance ankle and foot intrinsic strengthening
  • Pool running progressing to dry land
  • Linear progressing to lateral and rotational functional movements
  • Bilateral progressing to unilateral plyometric activity

Phase 4- Advanced strengthening (weeks 12-16)[edit | edit source]

  • Advance impact and functional progressing
  • Sport specific drills on field or court with functional brace
  • Sport test at 3-4 months based on progress [18]

For a long-term care in order to reduce a fracture risk it is important to:

  • Wear appropriate footwear;
  • Follow a diet full of calcium-rich foods such as milk, yogurt, and cheese to help build bone strength;
  • Do weight-bearing exercises to help strengthen bones.[13]

Resources[edit | edit source]

References[edit | edit source]

  1. 1.0 1.1 1.2 Fields K. Stress fractures of the tibia and fibula. UpToDate. Available from:https://www.uptodate.com/contents/stress-fractures-of-the-tibia-and-fibula (accessed 27-1-2019).
  2. https://ukhealthcare.uky.edu/orthopaedic-surgery-sports-medicine/sports-medicine/coaches-trainers/fibular-fracture (accessed 2 Februar 2019).
  3. Zammit J, Singh D. The peroneus quartus muscle. Anatomy and clinical relevance. J Bone Joint Surg Br 2003; 85:1134.
  4. Horwitz DS, Kubiak EN. Surgical treatment of osteoporotic fractures about the knee. Instr Course Lect 2010; 59:511-23.
  5. Lauge-Hansen N: Fractures of the ankle: combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950;60(5):957-985.
  6. Jehlicka D, Bartonícek J, Svatos F, Dobiás J. [Fracture-dislocations of the ankle joint in adults. Part I: epidemiologic evaluation of patients during a 1-year period]. Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca. 2002 ;69(4):243-247.
  7. Lee A, Geoghegan L, Nolan G, Cooper K, Super J, Pearse M, et al. Open tibia/fibula in the elderly: a retrospective cohort study. JPRAS 2021; 31:1-9.
  8. Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF. Foot and ankle fractures in elderly white women. Incidence and risk factors. J Bone Joint Surg Am 2003; 85-A:820.
  9. Makwana NK, Bhowal B, Harper WM, Hui AW. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective, randomised study. J Bone Joint Surg Br 2001; 83:525.
  10. Kelsey JL, Keegan TH, Prill MM, Quesenberry CP, Sidney S. Risk factors for fracture of the shafts of the tibia and fibula in older individuals. Osteoporos Int 2006; 17(1):143-149.
  11. Slauterbeck JR, Shapiro MS, Liu S, Finerman GA. Traumatic fibular shaft fractures in athletes. Am J Sports Med 1995; 23(6):751-754.
  12. Patton A, Bourne J, Theis JC. Patterns of lower limb fractures sustained during snowsports in Otago, New Zealand. N Z Med J 2010; 123(1316):20-25.
  13. 13.0 13.1 13.2 13.3 Higuera V. What to know about fibula fractures. Available from:https://www.medicalnewstoday.com/articles/315565.php (accessed 28-1-2019).
  14. Norvell J.Tibia and fibula fracture in the ED differential diagnosis. Available from:https://emedicine.medscape.com/article/826304-differential (accessed 28-1-2019).
  15. Backer H, Turner Vosseller J. Intramedullary fixation of fibula fractures: a systematic review. J Clin Orthop Trauma 2021; 18:136-143.
  16. Canton G, Sborgia A, Maritan G, Fattori R, Roman F, Tomic M, et al. Fibula fractures management. World J Orthop 2021; 12(5):254-269.
  17. Northwest Ohio Orthopedics and Sports Medicine. Rehabilitation guidelines for ankle ORIF. Available from: http://nwomedicine.com/wp-content/uploads/2014/09/ProtocolAnkleORIF.pdf (accessed 28-1-2019).
  18. The Orthopedic Partners. ORIF fibular fracture post-operative protocol. Available from: https://rcmclinic.com/patient-information/foot-and-ankle/orif-fibular-fracture-post-op/ (accessed 28-1-2019).