IMAJ • VOL 13 • JANUARY 2011
joint injury should raise a clinical suspi-
cion. There may be a bony prominence
over the lateral aspect of the knee; range
of motion may be full and may or may
not be associated with clicking. Ankle
movement may exacerbate knee pain.
Plain radiographs of both knees are used
as the first imaging modality. Computed
tomography is indicated if there is diag-
nostic uncertainty 
Our patient is a 27 year old amateur
athletic male who trained in capoeira
(an Afro-Brazilian art form that com-
bines elements of martial arts, music
and dance) for 4 years and who recently
started practicing acrobatics. On the night
he presented to the emergency room he
had jumped from a trampoline to a high
thought that many cases are undiagnosed
or not reported. This injury is described
in athletes, mostly professional but also
recreational, in the field of jumping, ballet
dancing, parachuting and snowboarding
. It is classified as either acute proxi-
mal tibiofibular dislocation or chronic
proximal tibiofibular instability [2,3]. In
his 1974 paper, Ogden  suggested a
modification to the classification offered
by Lyle in 1925. He described four types
of pathologies around the proximal
tibiofibular joint: Type I – Subluxation,
Type II – Anterolateral dislocation, Type
III – Posteromedial dislocation, and Type
IV – Superior dislocation. Of these, ante-
rolateral dislocation (Type II) is the most
common form of dislocation around this
joint, accounting for 85% of proximal
tibiofibular dislocations  and is the
one most commonly related to sports.
The mechanism of injury in this type is
of sudden internal rotation and plantar
flexion of the foot with an external rota-
tion of the leg and flexion of the knee.
This injury may be accompanied by an
associated transient peroneal palsy .
Early diagnosis and management is a very
important factor in the final outcome .
The diagnosis is essentially a clinical one.
All cases of lateral knee pain and a his-
tory suggesting a proximal tibiofibular
islocation of the proximal tibiofibular
joint is considered a rare injury. It is
mattress and onto a lower padded floor.
He recalls landing with his knee in hyper-
flexion and his ankle everted. After the fall
he felt tolerable pain while trying to bear
weight. He was brought by ambulance to
the emergency room.
Physical examination revealed a bony
prominence over the lateral aspect of the
knee, anterior to the head of the fibula.
There was no palpable effusion within
the joint and range of motion was limited
due to pain. An anterolateral dislocation
of the fibular head was suspected [Figure
A]. Peroneal nerve injury was sought, but
was not found. X-rays were taken in both
the anteroposterior and lateral position,
confirming the diagnosis [Figure 1B].
Reduction was attempted under
sedation using ketamin (0.5 mg/kg) and
midazolam (IV administration until
spontaneous eye closure, 2.5 mg for our
proximal tibiofibular joint dislocation,
lateral knee pain, hyperflexion injury,
fibular head, ankle pain
IMAJ 2011; 13: 62–63
Dislocation of the Proximal tibiofibular Joint: a rare
Yariv Goldstein MD, Aviram Gold MD, Ofir Chechik MD and Michael Drexler MD
Department of Orthopedics, Tel Aviv Sourasky Medical Center, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
[a] Photo taken in the emergency room before first reduction attempt
[B] Bilateral anteroposterior knee radiograph at presentation
case cOmmunicatiOns Download full-text
IMAJ • VOL 13 • JANUARY 2011
patient) and using direct pressure over the
dislocated fibular head. Two attempts at
reduction failed and the patient was trans-
ferred to the operating room where under
general anesthesia with full relaxation
another closed attempt was made, which
failed. Open reduction through a lateral
approach was then performed, using a
Hohmann retractor to lever the fibular
head back into place while preserving the
peroneal nerve. After reduction the joint
was stable and no other means of fixation
were deemed necessary.
The patient was examined the follow-
ing morning. Apart from pain related to
the surgical wound his knee had almost
full range of motion and he was able to
bear weight. He was reexamined for per-
oneal injury and was found to be intact.
He was discharged the following morn-
ing, with recommendations for protected
weight bearing on crutches for 3 weeks
and gradual progression to full weight
bearing over 6 weeks. He was seen in
the outpatient clinic after 2 weeks when
the staples were removed and the knee
assessed, at 6 weeks when full weight
bearing was allowed, and at 3 months
after the injury when he reported reach-
ing an activity level similar to that before
Proximal tibiofibular joint injuries are
considered a rare solitary finding and
are mostly related to sporting activities.
There are no clear guidelines as to the
best treatment in the acute setting. It is
proposed that in most cases reduction
can be achieved easily by applying direct
force over the joint. If a closed reduction
attempt fails, open reduction is needed.
There is no consensus regarding the
use of internal fixation following open
reduction. In our case, three attempts at
closed reduction failed, under both seda-
tion and general anesthesia. There is no
consensus on the post-reduction therapy
regimen. The literature suggests anything
from 6 weeks in non-weight bearing cast
immobilization to early range-of-motion
exercises. In our patient, full range-of-
motion exercises were allowed imme-
diately following surgery; while weight
bearing was limited for the first 3 weeks
with a gradual return to full weight bear-
ing over 6 weeks.
Dr. Y. goldstein
Dept. of Orthopedics, Tel Aviv Sourasky Medical
Center, 6 Weizmann Street, Tel Aviv 64239, Israel
Fax: (972-3) 697-4775, email: firstname.lastname@example.org
Ahmad R, Case R. Dislocation of the fibular head 1.
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Ogden JA. Subluxation and dislocation of the 2.
proximal tibiofibular joint. J Bone Joint Surg Am
1974; 56: 145-54.
Van Seymortier P, Ryckaert A, Verdonk P, 3.
Almqvist KF, Verdonk R. Traumatic proximal
tibiofibular dislocation. Am J Sports Med 2008;
Aladin A, Lam KS, Szypryt EP. The importance 4.
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