Case Report| Volume 57, ISSUE 4, P844-849, July 2018

Download started.


The Use of Pediatric Flexible Intramedullary Nails for Minimally Invasive Fibular Fracture Fixation

Published:April 13, 2018DOI:


      Fibular fractures in the setting of an unstable ankle joint require surgical fixation; however, several factors contradict open surgical correction. Severe soft tissue compromise can delay adequate fracture reduction and preclude the standard incisional approach. The soft tissue envelope in the setting of obesity, diabetes, and/or peripheral vascular disease further complicates definitive treatment. Poorly timed open fixation can lead to delayed healing of the incision site, with wound breakdown and the potential for hardware failure. Proximal fibular fractures are also at unique risk of neurovascular compromise with open reduction and internal fixation. Surgical fixation has now focused on minimizing the soft tissue insult using percutaneous techniques in the comorbid patient. We present a case that highlights a minimally invasive technique that provides dynamic stable internal fixation of fibular fractures with the use of flexible pediatric intramedullary nails, typically used in long bone fractures of children.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Thordarson D.B.
        Complications after treatment of tibial pilon fractures: prevention and management strategies.
        J Am Acad Orthop Surg. 2000; 8: 253-265
        • Dujardin F.
        • Abdulmutalib H.
        • Tobenas A.C.
        Total fractures of the tibial pilon.
        Orthop Traumatol Surg Res. 2014; 100: S65-S74
        • Watson J.T.
        • Moed B.R.
        • Karges D.E.
        • Cramer K.E.
        Pilon fractures: treatment protocol based on severity of soft tissue injury.
        Clin Orthop Relat Res. 2000; 375: 78-90
        • Cannada L.K.
        The no-touch approach for operative treatment of pilon fractures to minimize soft tissue complications.
        Orthopedics. 2010; 33: 734
        • Salton H.L.
        • Rush S.
        • Schubert J.
        Tibial plafond fractures: limited incision reduction with percutaneous fixation.
        J Foot Ankle Surg. 2007; 46: 261-269
        • McFerran M.A.
        • Smith S.W.
        • Boulas H.J.
        • Schwartz H.S.
        Complications encountered in the treatment of pilon fractures.
        J Orthop Trauma. 1992; 6: 195-200
        • Barry M.
        • Paterson J.M.H.
        Flexible intramedullary nails for fractures in children.
        J Bone Joint Surg Br. 2004; 86-B: 947-953
        • Kline A.J.
        • Gruen G.S.
        • Pape H.C.
        • Tarkin I.S.
        • Irrgang J.J.
        • Wukich D.K.
        Early complications following the operative treatment of pilon fractures with and without diabetes.
        Foot Ankle Int. 2009; 30: 1042-1047
        • Pollak A.N.
        • McCarthy M.L.
        • Bess R.S.
        • Agel J.
        • Swiontkowski M.F.
        Outcomes after treatment of high-energy tibial plafond fractures.
        J Bone Joint Surg Am. 2003; 85: 1893-1900
        • Wang Q.
        • Xu H.G.
        • Zhang Y.C.
        • Dong L.J.
        Elastic nails for fibular fracture in adult tibiofibular fractures.
        Int J Clin Exp Med. 2015; 8: 10086-10090
        • Megas P.
        • Zouboulis P.
        • Papadopoulos A.X.
        Distal tibial fractures and nonunions treated with shortened intramedullary nail.
        Int Orthop. 2003; 27: 348-351
        • Duchesneau S.
        • Fallat L.M.
        The Maisonneuve fracture.
        J Foot Ankle Surg. 1995; 34: 422-428
        • Stufkens S.A.
        • van den Bekerom M.P.J.
        • Doornberg J.N.
        • van Dijk C.N.
        • Kloen P.
        Evidence-based treatment of Maisonneuve fractures.
        J Foot Ankle Surg. 2011; 50: 62-67
        • Crist B.D.
        • Khazzam M.
        • Murtha Y.M.
        • Della Rocca G.J.
        Pilon fractures: advances in surgical management.
        J Am Acad Orthop Surg. 2011; 19: 22
        • Smith M.
        • Medlock G.
        • Johnstone A.J.
        Percutaneous screw fixation of unstable ankle fractures in patients with poor soft tissues and significant co-morbidities.
        Foot Ankle Surg. 2015; 23: 16-20
        • Vallier H.A.
        • Le T.T.
        • Bedi A.
        Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing.
        J Orthop Trauma. 2008; 22: 307-311
        • Rehman H.
        • McMillan T.
        • Rehman S.
        • Clement A.
        • Finlayson D.
        Intramedullary versus extramedullary fixation of lateral malleolus fractures.
        Int J Surg. 2015; 22: 54-61
        • Loukachov V.V.
        • Birnie M.F.
        • Dingemans S.A.
        • de Jong V.M.
        • Schepers T.
        Percutaneous intramedullary screw fixation of distal fibula fractures: a case series and systematic review.
        J Foot Ankle Surg. 2017; 56: 1081-1086
        • White T.O.
        • Bugler K.E.
        • Appleton P.
        • Will E.
        • McQueen M.M.
        • Court-Brown C.M.
        A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients.
        Bone Joint J. 2016; 98–B: 1248-1252
        • Evans J.M.
        • Gardner M.J.
        • Brennan M.L.
        • Phillips C.J.
        • Henley M.B.
        • Dunbar R.P.
        Intra-medullary fixation of fibular fractures associated with pilon fractures.
        J Orthop Trauma. 2010; 24: 491-494