Alternative Fixation of a Comminuted Fibular Head Avulsion in a Patient With an Ipsilateral Tibial Intramedullary Nail: A Hybrid Construct Case Report.
4 affiliations
- 1Orthopedics, Kern Medical Center, Bakersfield, USA.
- 2Surgery, Bakersfield Memorial Hospital, Bakersfield, USA.
- 3Orthopedics, Western University of Health Sciences, Pomona, USA.
- 4Orthopedic Surgery, Kern Medical Center, Bakersfield, USA.
Abstract
Fibular head avulsion fractures are uncommon injuries that disrupt the posterolateral corner of the knee and are frequently accompanied by injury to the adjacent common peroneal nerve. Current fixation options, cannulated screw fixation, locking compression hook plates, and suture anchor or transosseous repair, generally require either a fragment large enough to accept a screw or an intact, unobstructed proximal fibula for tunnel placement. We report a 33-year-old male pedestrian struck by a motor vehicle. He had an open proximal tibial fracture treated with intramedullary nailing and, approximately one week later, was found to have a comminuted fibular head avulsion. He also sustained posterolateral corner disruption, common peroneal nerve palsy, and a positive Lachman exam. The retained tibial intramedullary nail constrained conventional screw trajectories and bone-tunnel placement, while comminution of the avulsion fragment hindered reliable single-implant fixation. The fragment was stabilized with a hybrid construct combining transosseous Krackow sutures of FiberWire through the biceps femoris tendon, passed via Beath pins and tied over the anteromedial tibia. Additionally, a three-hole 3.5 mm locking compression plate (LCP) hook plate was applied to buttress the proximal fibula, along with primary repair of a mid-substance LCL tear, and formal common peroneal neurolysis. Examination under anesthesia after fixation demonstrated reduction of varus stress gapping from +3 to neutral. At nine weeks, the patient had knee range of motion of 0° to 115°, had advanced to weight-bearing as tolerated, and demonstrated maintained reduction with intact hardware and interval healing on radiographs. The common peroneal nerve palsy subsequently resolved completely; given full clinical recovery, electromyography was not indicated. This case describes a reproducible alternative technique for fibular head avulsion complicated by comminution and retained intramedullary hardware.
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BibTeX
@article{murthy2026alternative,
title = {{Alternative Fixation of a Comminuted Fibular Head Avulsion in a Patient With an Ipsilateral Tibial Intramedullary Nail: A Hybrid Construct Case Report.}},
author = {Kannan Murthy and Tiffany T Nguyen and Akshay Som and Youssef Messiha and Najib Ussef},
journal = {Cureus},
year = {2026},
month = sep,
doi = {10.7759/cureus.117027},
url = {https://europepmc.org/article/MED/42952478},
note = {CC BY},
}
RIS
TY - JOUR
TI - Alternative Fixation of a Comminuted Fibular Head Avulsion in a Patient With an Ipsilateral Tibial Intramedullary Nail: A Hybrid Construct Case Report.
AU - Kannan Murthy
AU - Tiffany T Nguyen
AU - Akshay Som
AU - Youssef Messiha
AU - Najib Ussef
PY - 2026
DA - 2026/09/27
JO - Cureus
DO - 10.7759/cureus.117027
UR - https://europepmc.org/article/MED/42952478
AB - Fibular head avulsion fractures are uncommon injuries that disrupt the posterolateral corner of the knee and are frequently accompanied by injury to the adjacent common peroneal nerve. Current fixation options, cannulated screw fixation, locking compression hook plates, and suture anchor or transosseous repair, generally require either a fragment large enough to accept a screw or an intact, unobstructed proximal fibula for tunnel placement. We report a 33-year-old male pedestrian struck by a motor vehicle. He had an open proximal tibial fracture treated with intramedullary nailing and, approximately one week later, was found to have a comminuted fibular head avulsion. He also sustained posterolateral corner disruption, common peroneal nerve palsy, and a positive Lachman exam. The retained tibial intramedullary nail constrained conventional screw trajectories and bone-tunnel placement, while comminution of the avulsion fragment hindered reliable single-implant fixation. The fragment was stabilized with a hybrid construct combining transosseous Krackow sutures of FiberWire through the biceps femoris tendon, passed via Beath pins and tied over the anteromedial tibia. Additionally, a three-hole 3.5 mm locking compression plate (LCP) hook plate was applied to buttress the proximal fibula, along with primary repair of a mid-substance LCL tear, and formal common peroneal neurolysis. Examination under anesthesia after fixation demonstrated reduction of varus stress gapping from +3 to neutral. At nine weeks, the patient had knee range of motion of 0° to 115°, had advanced to weight-bearing as tolerated, and demonstrated maintained reduction with intact hardware and interval healing on radiographs. The common peroneal nerve palsy subsequently resolved completely; given full clinical recovery, electromyography was not indicated. This case describes a reproducible alternative technique for fibular head avulsion complicated by comminution and retained intramedullary hardware.
SN - 2168-8184
ER -