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Proximal tibiofibular dislocation associated with fracture of the tibia: a case report
Cases Journal volume 2, Article number: 196 (2009)
We report a case of proximal tibiofibular dislocation associated with an ipsilateral tibial fracture, a rare association of injuries that can remain undiagnosed.
A white 23-year-old man experienced a road accident and was diagnosed with proximal tibiofibular dislocation associated with an open fracture of the tibia and injury to the external popliteus sciatic nerve. He was treated immediately with an intramedullary tibial nail and a cancellous screw at the level of the proximal tibiofibular articulation.
In addition to this case and the surgical treatment, a review of the clinical cases described in the literature is provided, assessing the type of injury and the therapeutic options used, which depend mainly on the stage in which the condition is diagnosed.
Proximal tibiofibular dislocation is an uncommon condition, with 100 cases described up to 1974, when the longest series, which contained 43 patients, was presented . This injury presents as isolated dislocation or chronic instability of the proximal tibiofibular articulation. Association of this condition with other injuries such as tibial fracture is the result of high-energy mechanisms, hence they are usually seen in polytrauma patients. Ogden reported 6 cases of proximal tibiofibular dislocation associated with fracture of the tibia in his series of 43 injuries . However, the number of proximal tibiofibular dislocations associated with tibial fracture in the literature represents only a small percentage of the total of tibiofibular dislocations [2–10].
A 23-year-old white European Spanish man experienced a motorcycle accident. In the initial examination, the left lower extremity showed deformation and swelling, with multiple injuries and bruises. Distal pulses were palpable and symmetrical. A functional deficit of the extensor muscles of the left foot was noted, raising the suspicion of injury to the external popliteal sciatic nerve.
The x-ray study confirmed the suspected diagnosis of an open, Gustilo grade IIIA diaphyseal fracture of the tibia (Figure 1), and revealed an associated proximal anterolateral tibiofibular dislocation (Figure 2).
The tibial fracture was treated with an intramedullary nail, performing Friederich debridement of the injuries together with removal of two bone fragments that were displaced from the focus of the fracture. The proximal tibiofibular dislocation was reduced, but due to instability, internal fixation by osteosynthesis with a cancellous screw at the level of the fibular head was carried out to hold reduction. During surgery, we observed an intramural hematoma and lengthening at the level of the external popliteal sciatic nerve. The distal syndesmotic ligaments and the interosseous membrane were not assessed because were stable at the distal part. Only a compressive bandage was used in the postoperative period.
During the early postoperative period, a 1.5 to 2 cm diastasis was detected in the tibial fracture, due to fibular length and bone loss. Based on this finding, surgery was again decided at 3 months when no sign of consolidation was observed. This consisted of an osteotomy with resection of 1 cm of fibula, dynamization of the fracture, nail impaction and bone graft contribution (Figure 3). Correct consolidation of the fracture and electromyographic signs of partial popliteal sciatic nerve recovery were observed in subsequent tests.
Two years after the accident, the tibial fracture was completely consolidated, although electromyographic signs of neurological injury persisted at the level of the deep fibular nerve.
The related literature contains only 9 articles describing proximal tibiofibular dislocation associated with tibial fracture, involving a total of 24 cases, with the longest series including 9 such fractures (Table 1). In most cases, the injury occurred in polytrauma patients who had experienced traffic accidents. The majority were driving a motorbike or had been run over; in two cases the injury was sustained in a car accident. In addition, there was one boat accident, one fall from a horse, and one industrial accident. Only three patients were women[2, 7] and there was one child. Patient age ranged from 6 to 55 years, with an average of 24.7 years. Our patient was 23, in keeping with the average age of the cases described.
Ogden described four types of proximal tibiofibular dislocation: subdislocation (type I), anterolateral (type II), posteromedial (type III) and superior (type IV). The dislocation patterns associated with tibial fracture include the superior type (14 cases), which always has an associated tibial fracture; the anterolateral type (3 cases), in which isolated tibiofibular dislocation most frequently appears; and the posteromedial type (3 cases). Gabrion described four cases of a type of inferior dislocation produced by high-energy mechanisms; these were associated with tibial fracture and serious vascular injuries, and required urgent amputation.
Proximal tibiofibular dislocation can easily go unnoticed when associated with and ipsilateral tibial fracture in polytrauma patients[1, 4, 5, 8–10, 12]. The absence of specific signs and symptoms in the physical examination, the presence of serious associated injuries, and the fact that conventional radiology may not provide useful findings, make a high clinical suspicion together with specific imaging studies, such as computed tomography or comparative x-rays, necessary to establish the diagnosis[1, 12, 13]. For this reason, some authors believe that the frequency of this entity may be underestimated[4, 6].
In 11 out of the 24 cases reported in the literature, an injury associated with the external popliteal sciatic nerve is described. Superior dislocations most often caused popliteal sciatic nerve injury (6 cases), although all the dislocations described as inferior by Gabrion had this associated injury (4 cases). Our case of anterolateral dislocation is the unique case reporting nerve injury in this type of dislocation.
Patients who completely recovered from the popliteal sciatic nerve injury (4 of the 11 cases with a nerve lesion) received treatment for the tibiofibular dislocation during the first days following the injury (except for one case treated 2 months later), whereas permanent injuries (2 cases) were treated at 3 weeks and 16 months post-trauma. The 5 remaining cases involving popliteal sciatic nerve injury required urgent amputation and the evolution of the neurological lesion could not be assessed. In the case presented herein, the external popliteal sciatic nerve injury occurred in a proximal tibiofibular dislocation of the anterolateral type, the only reported case of this association. The patient was treated urgently for tibiofibular dislocation, but partial injury of the popliteal sciatic nerve persisted two years later.
Treatment for tibiofibular dislocation should be carried out as early as possible to avoid chronic joint instability[4, 6, 9, 10, 12]. In cases of dislocation with a tibial fracture, the reduction of the tibial fracture is done first and usually the tibiofibular dislocation is done by itself[2, 3, 5]. Unstable reduction can be holded with a proximal tibiofibular screw [4, 6, 7, 10, 12] or K-wires [9, 12]. Other therapeutic options, often used in cases in which the dislocation is diagnosed later, include removal of the fibula head [8–10] or peroneal osteotomy. In the case presented, orthopedic reduction was unstable and osteosynthesis with a proximal tibiofibular screw was carried out. Diastasis of the tibial fracture detected in subsequent tests was treated by osteotomy with removal in the distal third of the fibula. New techniques are now available for treating proximal tibiofibular instability, but their use in patients with this injury and an associated tibial fracture has not been described[12, 14–16].
Proximal tibiofibular dislocation associated with a tibial fracture is an infrequent condition occurring in patients with polytrauma. Because it is rare, this entity can sometimes go unnoticed, delaying the diagnosis. Treatment with Kirschner wires or a temporary tibiofibular screw, carried out during surgery for the tibial fracture, provides good long-term results.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Ogden JA: Subluxation and dislocation of the proximal tibiofibular joint. J Bone Joint Surg Am. 1974, 56 (1): 145-54.
Brana VA, Mieres BP, Montes MS: Traumatic luxation of the proximal tibiofibular joint, superior variety. A case report. Acta Orthop Belg. 1983, 49 (4): 479-82.
Burgos J, Varez-Montero R, Gonzalez-Herranz P, Rapariz JM: Traumatic proximal tibiofibular dislocation. J Pediatr Orthop B. 1997, 6 (1): 70-2.
de la Caffiniere JY, Meyer M: [Superior fibulo-tibial traumatic luxation with fracture of the tibia. Apropos of 2 cases and a general review of the literature]. Rev Chir Orthop Reparatrice Appar Mot. 1988, 74 (4): 366-9.
Dewijze M, Duriau F, Tondeur G: [Traumatic superior peroneotibial luxation]. Acta Orthop Belg. 1979, 45 (5): 559-66.
Gabrion A, Jarde O, Mertl P, de Lestang M: Inferior dislocation of the proximal tibiofibular joint: a report on four cases. Acta Orthop Belg. 2003, 69 (6): 522-7.
Joshi RP, Heatley FW: Dislocation of superior tibio-fibular joint in association with fracture of the tibia: 'Monteggia' injury of the leg. Injury. 1997, 28 (5-6): 405-7. 10.1016/S0020-1383(97)00046-6.
Levy M: Peroneal nerve palsy due to superior dislocation of the head of the fibula and shortening of the tibia (Monteggia-like fracture dislocation of the calf). Acta Orthop Scand. 1975, 46 (6): 1020-5.
Shelbourne KD, Pierce RO, Ritter MA: Superior dislocation of the fibular head associated with a tibia fracture. Clin Orthop Relat Res. 1981, 172-4. 160
Valenti P, Nordin JY: [Post-traumatic dislocation of the upper tibiofibular joint. Review of the literature apropos of 6 cases]. Rev Chir Orthop Reparatrice Appar Mot. 1989, 75 (2): 112-9.
Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976, 58 (4): 453-8.
Sekiya JK, Kuhn JE: Instability of the proximal tibiofibular joint. J Am Acad Orthop Surg. 2003, 11 (2): 120-8.
Keogh P, Masterson E, Murphy B, McCoy CT, Gibney RG, Kelly E: The role of radiography and computed tomography in the diagnosis of acute dislocation of the proximal tibiofibular joint. Br J Radiol. 1993, 66 (782): 108-11. 10.1259/0007-1285-66-782-108.
White SH: Bicipetal tenodesis for anterior subluxation of the superior tibiofibular joint. J Bone Joint Surg Br. 2001, 83 (8): 1176-7. 10.1302/0301-620X.83B8.11963.
Cazeneuve JF, Bracq H, Meeseman M: Weinert and Giachino ligament arthroplasty for the surgical treatment of chronic superior tibiofibular joint instability. Knee Surg Sports Traumatol Arthrosc. 1997, 5 (1): 36-7. 10.1007/s001670050021.
Miettinen H, Kettunen J, Vaatainen U: Dislocation of the proximal tibiofibular joint. A new method for fixation. Arch Orthop Trauma Surg. 1999, 119 (5-6): 358-9. 10.1007/s004020050428.
The authors declare that they have no competing interests.
OA performed the clinical follow-up and write the article.
XC performed the bibliographic research and write the article.
RS performed the clinical follow-up and contribute to the write article.
LC performed the emergency and surgical treatment.
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Ares, O., Conesa, X., Seijas, R. et al. Proximal tibiofibular dislocation associated with fracture of the tibia: a case report. Cases Journal 2, 196 (2009). https://doi.org/10.1186/1757-1626-2-196
- Tibial Fracture
- Cancellous Screw
- Electromyographic Sign
- Proximal Tibiofibular Articulation
- Fibular Nerve