Spiral fracture fibula distal end

d014,

It sounds like you have a syndesmosis injury besides the fibular fracture. The long, horizontal screw placed across the tibiofibular joint (from the fibula into the tibia), is to hold the tibia and fibula reduced.

This is usually done by the syndesmosis. A broad, long, stout ligament that runs in between the tibia and the fibula for almost the full length of the two bones. When the syndesmosis is ruptured, the tibia and fibula spread apart. This disrupts the mortise joint of the ankle.

So, the fibular fracture is reduced and plated and then the syndesmosis widening is reduced and held with a transfixation screw. Sometimes two parallel screws are used, whatever is needed to hold the two bones together.


The problem with weight bearing is that you would probably break the syndesmosis screw before the ligament was healed. Then the bones would spring apart again and you would have a malaligned ankle joint. This would then lead to traumatic arthritis and chronic pain.

So, usually, most surgeons will keep the patient nonweight bearing for around 8 weeks (give or take) and then remove the syndesmosis screw before allowing a lot of weight bearing.

The reason to take the screw out, before allowing weight bearing is two fold. The breaking of the screw is one. The other has to do with the physiological movement of the tibiofibular joint.

With normal weight bearing, the distal ends of the tibia and fibular spread apart ever so slightly. This tiny amount of spreading and movement allows for cushioning and also to allow for ankle range of motion. The talus (the third bone in the ankle mortise) is actually wider in the front of its dome than in the back. So, to accommodate the difference in the talar width with ankle dorsiflexion and plantarflexion (moving the ankle up and down), the tibia and fibula have to move apart just slightly.

The screw does not allow this motion.


So, that is most likely why you are no allowed to weight bear. You should discuss with your surgeon his/her plans for the syndesmosis screw. Most surgeons take it out before weight bearing, but others begin weight bearing with it in, and take it out later. And, there is a small group, that never removes the screw, unless it breaks and causes problems. Again, that is a small group.

You need to discuss your treatment plan with your surgeon so you can make plans for your rehab. It is sometimes difficult to regain ankle motion after an ankle fracture, let alone with a syndesmosis injury. You will also have significant calf muscle atrophy.

So, you will have to work hard in therapy to regain ankle motion and strength. And this can take quite a while.


Good luck.

Thank you for your reply How will I know if the screw have moved or snapped. I have been weightbearing on it with the use of crutches I dont have no pain in it when I have been putting weight on it.

d014,

If you do not have any pain there, you are probably okay.

The screw will fail in one of two ways. It will have a instantaneous failure with a snap, just like if you broke a stick. And that would probably hurt, so you would know it that happened.

The other way, is a stress fracture. With repetitive bending, the screw will final break in two. Just like a paper clip that has been bent back and forth once too often. This probably would not hurt. The only way of telling is with an x-ray.


But, you might want to contact your surgeon and ask about your weight bearing status. Ask if it is okay to put a little weight on it while using your crutches. It is really up to your surgeon.

Hang in there. There is usually a reason why the surgeon does not want you bearing weight. But, you can always ask. Good luck.

thank you for your fast replies.

Sorry one last question how did the drs know I had Syndesmotic ligaments just by X-rays?

Yep. And also with a stress test during surgery.

When you look at the AP view of the ankle, if the mortise iswidened, that means that the ligament holding the tibia and fibula together is no longer working.

There are many patterns of ankle fractures. Through years of research, the orthopedic community has developed several different classification systems. So, during training, orthopedic surgeons have these drilled into them, so when they look at the films, they can usually tell exactly what type of forces have been applied to the bones and ligaments. And, as a result, what has been torn or broken.


So, it is usually pretty easy to see a syndesmosis injury. However, there are some that are sneaky. So, during surgery to fix the bones the surgeon is take a bone hook and place it around the fibula, and pull. This is done under the C-arm (real time x-ray) so the surgeon can tell if the syndesmosis is intact. If the mortise widens with the stress test, then the surgeon will go ahead and stabilize it with a screw.


Hope that helps. Good luck with your rehab.

thank you for your advice once again where did you learn all this lol you know some pretty serious medical stuff...... also what is the average syndesmosis healing time?

Dan

Dan,

Usually, it takes about 6-8 weeks for a ligament to heal, physiologically. But, that can vary from patient to patient.

Most of the time, surgeons will plan on taking a syndesmosis screw out around that time or a little later. But again, that varies too, from surgeon to surgeon.

You should contact your surgeon to see if he/she is planning to take the screw out, or ask at your next appointment. As every case is different.

Hang in there, this too shall pass. Good luck.

my consultant said that they would leave the metal work in does that sound right?

Dan,

If the hardware is for the fixation of the ankle fracture, it can be left in forever.

It is the one screw, that goes from the fibula into the tibia, that is of concern. If it is a syndesmosis screw, then usually they are removed. But, not always. Some surgeons elect to just leave them in and deal with it if it breaks and causes problems.

A syndesmosis screw is very long, goes horizontally from the fibula into the tibia (usually all the way across the tibia or almost all the way). It is parallel to the top of the talus. It is usually a little bit bigger, in caliber, than the cortical screws used to hold a plate on.


Again, discuss this with your surgeon. It may be that the screw is not a syndesmosis screw, but just one placed for fixation of the fracture. When you see your surgeon, have him/her explain what each of the screws is doing and what exactly your injuries are.

Hope that was not too confusing. Good luck.

Hi I been to see my consultant today they have not screwed my tiba and fibula together the consultant said that there is nothing wrong with my ligaments and I will start weight bearing in 2 weeks

d014,

Excellent. Sounds like the surgeon was just being extra cautious in terms of letting you weight bear. You had noted in your first message that there was a screw from the fibula into the tibia. I guess that was not the case then. That's good. You do not want to have a syndesmosis injury, they can cause problems down the road.

Are they going to let you weight bear in the cast, or transition you to weight bearing and range of motion all at once (fracture brace)? Some surgeons place a walking cast so the patient can get used to weight bearing without having to worry about range of motion also. Other, just go straight to a fracture brace and allow the patient to start both.


Either way, have you crutches handy when you first try to walk. Don't expect to just walk out of the surgeon's office. You will have to advance your ambulation. Some patients can walk in a short leg walking cast without many difficulties.

But, if you start range of motion at the same time, expect some significant stiffness and soreness in the ankle joint. You will also have calf muscle atrophy (loss of muscle strength).



Good luck. Hope you progress rapidly on your rehabilitation.

Hi I have a quick question I went to see my surgeon and he xrayed it and said the bones bones have fused and I am fully weight bearing with no crutches but I am noticing a lot of swelling in my ankle but it is not painful is this normal?