Closed Versus Open Reduction of Fibular Fractures: Decision-Making Pearls

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My name is Brett Smith. I'm a DO and I currently reside in Durango, Colorado, which is nowhere near Denver. That's your question you're thinking about. We're in a little mountain town in the southern terminus of the Rockies. It's a great little place to live. Training was in Philadelphia for Medical School, PCOM, Columbus, Ohio, at the Ohio Health System for my residency in orthopedic surgery. And then I spent a year at Orthopedic Foot and Ankle Fellowship at the Orthopedic Foot and Ankle Center in Columbus, Ohio, under the tutelage of Tom Lee, Greg Berlett, Terry Philbin, and Chris Hyer.
 
In your experience, what are some challenges or pitfalls providers face when determining  whether to open or closed-reduce a fibular fracture?
 
To me, that's a great question, and I think there's been some recent research that really suggests to us that getting a really solid reduction, anatomic reduction, is probably quite important for overall ankle mechanics and long-term health of the ankle joint. I think for any of us that treat ankle fractures, we should always be thinking, is this somebody we're gonna see in the future who needs that ankle replacement or ankle fusion.
 
And so restoring anatomy, a lot of times I think of it in my own head of, yes, I'm gonna treat you now to get you as good as I can get you and get you back to your activities. But ultimately I'm also thinking, well, if I do a really great job, maybe they can either avoid or delay something else in the future. I think with fibular fractures, to me it's always a very complex algorithm I go through to some degree in my own head, not just the fracture pattern itself, but really I have to look at the entire patient from a holistic standpoint.
 
Is this somebody who's going to do well with ORIF? Or are they gonna do well with closed reduction? And that can play into several factors, looking at their soft tissue envelope, their relative health status. Overall, I look at people from a nutrition standpoint, a hormone standpoint, vitamin D levels, all those things are playing through my mind when I'm thinking about treating fractures around the ankle. And I think for me, I have a fairly low threshold for treating fibular fractures with ORIF, especially in indications where I for sure think they are needed.
 
And one of the biggest advantages to me anyway is if I have an unstable fracture pattern or something I'm concerned about, I can potentially get that person moving and back to weight-bearing earlier with the ORIF, which to me is massive, getting that foot on the ground, getting that person up and about. I think it has physical benefits for sure, but also mental benefits as well, getting that person back to being active.
 
I currently live, like I said, in a small mountain community in Colorado. I have people here who, all they wanna do is run up and down mountains all day long and ride their bikes and hike and rock climb and ski and snowboard. So it's a very active community. Very much in contrast to my first practice, I was in Columbia, South Carolina for about 12 or 13 years and very, very different demographic. I was a bit shocked when I first came here about six years ago into practice how I would be, you know, kind of floored by the person chart I was reading outside the door and then walking inside the door and going, wait a second, you're 85, you take no meds and you're absolutely fit. And so it really had to change my mind and my thought process about who I'm treating and what I'm treating because my community changed so radically from sort of the southeast region of the US to the western mountain region.
 
What does the literature currently demonstrate on this topic?
 
I think what we're seeing and there's probably, there's always multiple schools of thought, but I'd say the two main schools of thought are that I know there's a very strong sort of faction within the US currently that is looking at, you know, really doing some really cool studies with three-dimensional CT weight-bearing scans, looking at does displacement alter ankle mechanics as a fibular fracture. And there's actually some pretty good data showing there are some alterations. There's some question on that, whether or not it's pressure component versus a weight-bearing component, but there is an alteration and they're starting to tease some of that out.
 
I was just at a, well, the winter meeting in, up in Montana, Big Sky last winter, I was on a panel and one of the topics was looking at this very thought process of altered mechanics within the ankle after fibular fracture using utilizing weight-bearing CT scans and fastening material. I don't think that's gone quite out the publication yet. It was at that point still being finalized, but a very interesting discussion.
 
I think though if you look in some other literature, especially out of the European world, especially I know Great Britain has kind of led the charge on this is they have a very, very defined algorithm about treating nonoperative versus operative ankle fractures.
 
Now, obviously, we were looking at a little bit of an apple to an orange comparison because you have a nationalized health system in one and you have an open health system in the other countries. So there is definitely some contrast, but I actually tend to follow along with one of the guidelines that came of the UK looking at isolated fibular fractures that are shown to be stable patterns with minimal displacement. I will definitely tend to treat those conservatively.
 
And I'll, but I do follow those patients very, very closely. I'll see them, I'll look at them. I'll say, I think this is a pattern that we can trust will be stable, but I don't believe myself until I've proved it to myself.
 
So the first thing I do is I schedule it automatically back one week for a follow-up X-ray. So I re-X-rayed them within a week of them being, I use CAM boots, not casts, but that's just my preference. But I follow them very, very closely.
 
There's any hesitation or thought process in my mind. I'll immediately move to ORIF or if I'm just on that really, on that really funky fence where I'm like person, maybe he's not the best surgical candidate, but I think this is going to be okay. I'll break them back one week after that and extra again to make sure that there has been no change in position. So I'm pretty neurotic when I come to treating the non-operative patients with those fracture patterns.
 
So I think there's a lot of literature out there that kind of helps us maybe to some degree. And I appreciate what the UK folks had done with their guidelines. And one of the reasons those guidelines came out actually was really to help the resident who was seeing that patient in the emergency room and to try to set that up for success. Could that person be seen in clinic the next day for surgery or could that person be put into splint device of some sort or, you know, boot and follow up in a week. So it was really to help, I think the folks there on the kind of boots on the ground folks really have an algorithm that they could go to that was backed up with some very good data.
 
And having a nationalized health service like that, you can get that kind of data very easily because you haven't really captured in the same database. Our challenge here in the US is we don't really have a lot of those captured databases. So it does make things a little bit more challenging to collect those large pools of data.
 
Like I said, some of that newer literature coming out with the help and advent of technology like the weight-bearing CTs, which is I feel going to be revolutionary within the foot and ankle space. And I think it's already had a massive impact. And I just, I'm actually kind of those things where I'm kind of giddy to see what we're gonna learn even more from that technology as we progress forward.
 
But we're also seeing that by teasing out some of this sort of very, very fine data from some of these studies looking at weight-bearing CT and fibular fractures that maybe there is, you know, a lower threshold that we need to get to when treating these operatively.