Foot and Ankle Surgery 16 (2010) e63–e67
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Case report
Non-union of Weber B distal fibula fractures: A case series Lorcan McGonagle MRCS*, Peter Ralte MRCS, Steven Kershaw FRCS T+O Macclesfield District General Hospital, Victoria Road, Macclesfield, Cheshire, SK10 3BL, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 November 2009 Received in revised form 28 February 2010 Accepted 31 March 2010
Non-union of distal fractures of the fibula type Weber B is rare. Undisplaced and minimally displaced isolated lateral malleolar fractures (Weber B) usually unite without operative intervention. We present three cases of lateral malleolus non-union in healthy individuals. Two were treated with internal fixation plus bone grafting. The third patient remained asymptomatic and therefore did not undergo surgery for the fracture. ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Weber B Fracture Non-union Ankle
1. Introduction Non-union of distal fractures of the fibula type Weber B is rare. Isolated malleolar injuries account for two thirds of ankle fractures [1]. Fractures that are displaced, or are associated with talar shift/ medial ligament injury are considered unstable and are usually treated with open reduction and internal fixation [2]. Minimally displaced or undisplaced fractures at the level of the syndesmosis {Weber B} can be treated non-operatively with a period of cast immobilisation, with an excellent prognosis [3]. In the vast majority of cases this results in satisfactory fracture union, and functional outcome, provided the fracture has not displaced. We report three separate cases of undisplaced/minimally displaced Weber B fracture non-union.
Five days after the initial injury he attended the fracture clinic where a full plaster cast was applied and non-weight bearing advice was given. Forty days post-injury the plaster was removed. Although there was no pain over the fracture site, X-rays did not show evidence of fracture union. A dynacast splint was applied with the advice to partially weight bear for a further 2 weeks.
1.1. Case 1 A 51-year-old healthy man sustained an inversion injury to his left ankle while playing rugby. Although he was able to partially weight bear afterwards, he attended the emergency department (ED) 2 days later, where a distal fibula fracture was diagnosed (Fig. 1). There was no clinical evidence of medial ligament/malleolus injury at the time, and a back slab was applied.
* Corresponding author at: 7 Bryanston Road, Liverpool, L17 7AL, United Kingdom. Tel.: +44 0151 222 4415. E-mail address:
[email protected] (L. McGonagle).
Fig. 1. Case 1: ankle x-rays 1 day post injury.
1268-7731/$ – see front matter ß 2010 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2010.03.008
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Fig. 2. Case 2: ankle CT 13 months post injury.
Fig. 3. Case 3: ankle x-rays 1 week post injury.
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Fig. 4. Case 2: ankle CT 18 weeks post injury.
Eight weeks post-injury there was no pain over the lateral malleolus, only mild swelling. Movements were pain free, with minimal limitation in range of motion and he was advised to fully weight bear without any splintage. Fourteen weeks post-injury he was mobilising well, with full pain free ankle movements, mild medial swelling, but no pain medially or laterally. He was discharged from the clinic. A further ankle sprain during sport resulted in a re-referral 13 months after the original injury. Again all symptoms were medial. Subsequent computer tomography (CT) confirmed non-union (Fig. 2). The patient was referred to a tertiary foot and ankle centre where a MR arthrogram confirmed only medial joint synovitis only. This was debribed arthroscopically, resolving his symptoms. The lateral malleolus was not operated upon as it was asymptomatic.
1.2. Case 2 A 42-year-old healthy man slipped while walking on a wet wooden path sustaining an eversion injury to his left ankle (Fig. 3). There was no pain/tenderness medially. An undisplaced Weber B fracture was treated initially in the ED with a backslab, which was converted to a full plaster 4 days later. He remained non-weight bearing for 22 days post-injury. At this stage partial weight bearing through the plaster was advised. On review 43 days post-injury there was still tenderness at the fracture site. A further period of non-weight bearing was therefore advised in view of the ongoing pain. Eight weeks post-injury, the swelling and tenderness had decreased, therefore a walking boot was applied, with the advice to weight bear through this. Although he was able to weight bear at 12 weeks the ankle was still swollen and the walking boot was exchanged for an ankle aircast brace.
Fig. 5. Case 2: ankle x-rays 9 weeks post surgery.
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Fig. 6. Case 3: ankle x-rays on day of injury.
Ongoing tenderness at 18 weeks lead to a CT being performed which showed only minor callus formation (Fig. 4). The patient went on to have an open reduction and internal fixation with a 6 hole compression plate with autologous tibial bone graft and tutobone preserved cancellous bovine bone at 25 weeks. A backslab was applied with the non-weight bearing instructions. At 31 weeks, a dyno-cast was applied with toe touch weight bearing advised. This progressed to full weight bearing at 35 weeks. At 39 weeks he was fully mobile with only occasional pain at night. Nineteen weeks post-operatively he was fully mobile without any walking aid. There was minor discomfort with walking long distances. The patient had full pain free movement, with minor tenderness over the plate. X-rays confirmed fracture union (Fig. 5).
Twenty-five weeks post-operatively the patient had full pain free movement, was non-tender over the fracture site and with Xrays confirming union he was discharged. 1.3. Case 3 A 21-year-old healthy man sustained an inversion injury while playing football. He attended the ED the same day. X-rays confirmed the nature of the injury (Fig. 6). There was no medial pain/tenderness and a backslab was applied. This was converted to a full plaster 2 days later. Nonweight bearing advice was issued. Forty-three days later the plaster was removed, and he was noted to have minimal tenderness over the fracture site with a good range of movements within the ankle. He was advised to mobilise as tolerated without any additional support. At 14 weeks the ankle was painful, he was able to walk with a limp, but unable to take part in sport, and was tender over the fracture site. Subsequent CT showed a partial union posteriorly only (Fig. 7). He had improved slightly at 23 weeks, but was still unable to take part in sport, with focal tenderness. He underwent open reduction internal fixation with autologous tibial bone graft, lag screw and dynamic compression plate. Fibrous tissue was noted at the fracture site. A plaster was applied and he was instructed to remain non-weight bearing. Six weeks post-operatively the patient was placed into a walking boot and was encouraged to begin partial weight bearing progressing to full weight bearing over the subsequent 4–6 weeks. Physiotherapy was provided to help restore ankle movement. By 10 weeks post-operatively the patient was mobilising full weight bearing and pain free for over 1 mile, with no tenderness over the fracture site and. X-rays taken at 5 months after surgery procedure confirmed bony union (Fig. 8). 2. Discussion
Fig. 7. Case 3: ankle CT 14 weeks post injury.
Ankle fractures are common, with an incidence of approximately 130 fractures per 100,000 persons [4].
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Fig. 8. Case 3: ankle x-rays 5 months post surgery.
Conservative treatment of undisplaced or minimally displaced fractures has been shown to be successful. Long-term clinical follow-up studies by Bauer et al. [5] and by Kristensen and Hansen [6] of closed treatment of supination—external rotation stage II fractures reported 94–98% good functional results, even with 3 mm of fibular displacement. Yde and Kristensen found that surgery did not produce better results than closed treatment in supination—external rotation stage II injuries, even though only one of 35 patients (3%) who had closed treatment had anatomical reduction compared with 28 of 34 (82%) with operative treatment [7,8]. Undisplaced Weber B fractures without a medial injury are stable and are generally treated non-operatively [1,9]. Non-union of distal fibula fractures is rare [10]. There have been cases of distal fibula non-union that have been treated successfully with bone grafting and internal fixation [11–14]. This case series highlights that non-union of lateral malleolar fractures can be preceded by different mechanisms of injury, within a wide age range (22–54), and may not always be symptomatic. Common risk factors for non-union, e.g. smoking, diabetes, peripheral vascular disease, non-steroidal anti-inflammatory use, infection was not present in any of the cases. Previous discussions of similar cases have tried to predict risk factors for such nonunions [14], although this case series shows that it can occur with different mechanisms, ages and sex. Although such fractures usually unite with conservative treatment, non-union should be considered in cases with persistent pain. Non-union should be considered in all patients with ongoing pain. Persistent pain should be investigated by CT to assess for possible union.
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