Morphological study of proximal fibular fractures with concomitant tibial plateau fractures：an investigation of 223 cases

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Methods Data were retrospectively collected from a Level-1 trauma center between January 2011 and January 2024 by querying hospital information and picture archiving and communication systems with keywords "tibial plateau fracture" and "fibular fracture" or "fibular head fracture". Radiographic morphology was evaluated using standard anteroposterior radiographs and three-dimensional computed tomography (3D-CT), categorizing proximal fibular fractures into 13 predefined morphological patterns. Descriptive data, including fracture location, number of fragments, and degree of displacement, were recorded and classified. The distribution patterns of proximal fibular fractures were further correlated with the tibial plateau fractures, categorized according to the CT-based three-column classification system. Logistic regression analysis was conducted to identify the associations between specific tibial plateau fracture subtypes and proximal fibular fracture patterns. Results A total of 223 eligible patients (123 males) were included in the analysis. Group I, II, and III proximal fibular fractures were observed in 63 (28.3%), 121 (54.3%), and 39 (17.4%) patients, respectively. Within group II, subtype II3p was the predominant fracture pattern, occurring in 62 patients (51.3%). Subtypes II1p(L), II2p(L + P), and III3 were not identified in the cohort. Group I fractures did not occur in posterior column or combined lateral and posterior column fractures. Group II fractures were absent in isolated lateral column or combined medial and lateral column fractures. Group III fractures exclusively presented with combined lateral and posterior column or three-column fractures. Logistic regression indicated that group I proximal fibular fractures were significantly more associated with isolated medial column tibial plateau fractures, whereas group II fractures were significantly associated with lateral-posterior and medial-posterior column fractures compared to three-column fractures. Conversely, group III proximal fibular fractures were significantly more common with three-column fractures than with lateral-posterior column fractures. Conclusions The morphological diversity observed in proximal fibular fractures underscores the complexity and heterogeneity of concomitant tibial plateau fractures. Further clinical and biomechanical investigations are warranted to elucidate the pathomechanics underlying comminuted fibular fractures associated with tibial plateau injuries. Health sciences/Medical research Health sciences/Medical research/Epidemiology Health sciences/Medical research/Outcomes research tibial plateau fracture proximal fibula fracture computed tomography posterolateral corner classification CT-based three-column classification system Figures Figure 1 Figure 2 1. Introduction Proximal fibular fractures constitute a common clinical entity, presenting either as isolated injuries or in conjunction with more complex knee or ankle trauma. Despite their prevalence, these fractures have often been overlooked in clinical assessment, resulting in insufficient characterization of their radiographic patterns in current orthopedic literature[ 1 – 3 ]. Recent advances in the anatomical and biomechanical understanding of the posterolateral knee structures have underscored the clinical significance of proximal fibular fractures [ 3 , 4 ]. The proximal fibula exhibits a distinct pyramidal anatomy, serving as an essential anatomical landmark for the fibular insertion points of key posterolateral corner (PLC) structures, including the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon [ 3 , 4 ]. Given this anatomical configuration, the proximal fibula is critically involved in stabilizing the knee joint, particularly against varus loading, external rotation, and posterior tibial translation forces [ 7 – 9 ]. Hence, comprehensive characterization of fracture patterns in this region is clinically important to better understand injury mechanisms and optimize therapeutic strategies. Previous studies have offered valuable insights into specific fracture patterns such as arcuate fractures, correlating their radiographic features with the unique anatomy of the proximal fibula [ 8 ]. Our prior research similarly highlighted the frequent coexistence of proximal fibular fractures with tibial plateau fractures, prompting the development of a novel radiographic classification based on fracture location as visualized on plain X-rays [ 1 ]. Nevertheless, three-dimensional computed tomography (3D-CT) imaging has revealed substantially greater complexity and variability in proximal fibular fracture morphologies compared with traditional radiographic assessments. Thus, further in-depth morphological studies using advanced imaging modalities are warranted. The present study addresses this knowledge gap by systematically evaluating proximal fibular fracture patterns using 3D-CT imaging. Specifically, we aimed: (1) to categorize proximal fibular fractures into defined morphological subtypes based on comprehensive 3D-CT analyses and anatomical considerations, and subsequently determine the distribution characteristics of these subtypes; (2) to investigate the associations between proximal fibular fracture morphologies and tibial plateau fracture subtypes according to the established CT-based three-column classification system. The findings of this study could facilitate a deeper understanding of knee injury patterns and serve as a reference for further clinical and biomechanical research. 2. Patients and Methods 2.1. Study Design and Patient Selection This study retrospectively analyzed clinical and imaging data from patients admitted with tibial plateau fractures to the Department of Orthopedics at Gongli Hospital, affiliated with the Second Military Medical University, from January 2011 to January 2024. Eligible cases were identified using the hospital information system (Ruijin, China) with search terms "tibial plateau fracture" combined with "fibular fracture" or "fibular head fracture. "The study was approved by the Institutional Review Board of Gongli Hospital, and all methods were performed in accordance with the relevant guidelines and regulations.Due to the retrospective nature of the study, the need for informed consent was waived by the Institutional Review Board of Gongli Hospital. Exclusion criteria included: (1) Fibular hairline fractures or displaced segments less than 2 mm; (2) Pathological fractures secondary to severe osteoporosis or tumor involvement; (3) Concomitant fractures of the femur or distal tibia; (4) Unsatisfactory radiographic or computed tomography (CT) imaging, including poor patient positioning, image quality, or incomplete radiologic documentation. 2.2. Imaging and Data Acquisition Radiographic data, including standard anteroposterior (AP) and lateral X-rays, as well as three-dimensional computed tomography (3D-CT) scans, were digitally retrieved from the hospital's picture archiving and communication system (PACS, Centricity; Jinshida, China). 2.3. Morphological Classification of Proximal Fibular Fractures Based on fracture line characteristics and comminution patterns observed on 3D-CT scans, proximal fibular fractures concomitant with tibial plateau fractures were categorized into 13 predefined morphological conditions (Fig. 1 ). These conditions were classified into three main groups: Group I (Avulsion Fractures): Horizontal fracture line primarily indicating ligamentous avulsion. I1: Small avulsion fractures limited to the fibular styloid. I2: Superior cortical rim avulsions involving the arcuate ligament complex (classic "arcuate fractures"). I3: Fractures extending through metaphyseal bone without comminution. Group II (Cleavage and Comminution Fractures): Cleavage and comminution fractures of the fibular head, subdivided according to involvement of anatomical columns based on the model described by Takahashi et al. [ 6 ](medial, lateral, posterior columns; Fig. 2 ): II1p: Single-column fracture (M, L, or P); II2p: Two-column fractures (M + L, M + P, or L + P); II3p: Three-column fractures involving medial, lateral, and posterior aspects. Group III (Fibular Neck or Shaft Fractures): Fractures distal to the head involving the fibular neck or proximal shaft region: III1: Oblique fracture oriented from superomedial to inferolateral direction. III2: Horizontal or extensively comminuted fractures. III3: Oblique fracture oriented from inferomedial to superolateral direction. Tibial plateau fractures were concurrently classified using the established CT-based three-column classification system described by Luo et al. [ 9 ]. 2.4. Reliability Assessment and Observers To evaluate inter-observer reliability, two independent observers with differing expertise were recruited: an orthopedic trauma surgeon (Observer 1) with extensive clinical experience in fracture management, and a musculoskeletal radiologist (Observer 2) experienced in fracture imaging interpretation. Both observers were blinded to patient clinical outcomes and had no conflicts of interest. Prior to evaluation, each observer was provided with detailed schematic illustrations and written instructions regarding the morphological classification system. In cases of disagreement, a consensus was reached through collaborative review and discussion. 2.5. Statistical Analysis Data were initially collected and organized using Excel spreadsheets (Microsoft Corp., Redmond, WA), followed by independent verification for accuracy, completeness, and logical consistency. Verified data were then imported into Statistical Product and Service Solutions (SPSS, Version 20.0; SPSS Inc., Chicago, IL) for further analysis. Descriptive statistical methods were employed to summarize the distribution of fibular fracture morphologies. Logistic regression analyses were subsequently conducted to determine associations between specific proximal fibular fracture patterns and the tibial plateau fracture subtypes according to the three-column classification system. 3. Results From January 2011 to January 2024, a total of 479 patient records were initially retrieved using the keyword "tibial plateau fracture." Following further screening with additional keywords ("fibular fracture" or "fibular head fracture"), 285 records remained. After applying inclusion and exclusion criteria, 223 eligible cases (123 males, 100 females) were ultimately included in the analysis (Table 1 ). Table 1 Baseline characteristics of the study population Characteristics n (%) Gender Male 123 (55.2) Female 100 (44.8) Age ≤ 55 years 116 (52.0) > 55 years 107 (48.0) Injury types Traffic accident 117 (52.5) Fall from bicycle 52 (23.3) Slip down 54 (24.2) Multiple trauma Yes 47 (21.1) No 176 (78.9) Among these cases, proximal fibular fractures were categorized into group I (avulsion fractures, n = 63, 28.3%), group II (cleavage and comminution fractures, n = 121, 54.3%), and group III (neck or proximal shaft fractures, n = 39, 17.4%). Within group II, the most frequent subtype was II3p (three-part comminution), occurring in 62 patients (51.3%). Subtypes II1p(L), II2p(L + P), and III3 were not identified within our study cohort (Tables 2 and 3 ). Table 2 Distribution of 223 proximal fibula fractures according to the 3 groups, 13 hypothetical conditions I II III I1 I2 I3 II1p II2p II3p III1 III2 III3 II1p(M) II1p(P) II1p(L) II2p(M + L) II2p(M + P) II2p(L + P) 13 23 27 15 16 0 14 15 0 62 23 16 0 63 (28.3%) 121 (54.3%) 39 (17.4%) Table 3 : Distribution of proximal fibula fractures according to hypothetical conditions in the CT-based three-column tibial plateau fracture classification [deleted II1p(L), II2p(L+P), and III3 subgroups] hypothetical conditions for proximal fibular fractures CT-based three-column: n (%) I II III I1 I2 I3 II1p II2p II3p III1 III2 II1p (M) II1p (P) II2p (M+L) II2p (M+P) SMC n=21 （ 9.42%) 9 4 0 0 8 0 0 0 0 0 SLC n=17, （ 7.62%) 0 1 16 0 0 0 0 0 0 0 SPC n=12, （ 5.38%) 0 0 0 10 0 1 1 0 0 0 MC + LC n=4, （ 1.79%) 0 0 4 0 0 0 0 0 0 0 MC + PC n=38, （ 17.04%) 0 10 0 2 7 4 6 9 0 0 LC + PC n=53, （ 23.77%) 0 0 0 2 0 2 5 34 0 10 three columns n=78, （ 34.98%) 4 8 7 1 1 7 3 18 13 16 Abbreviations: CT, computed tomography; LC+ PC, lateral columns+ posterior columns; MC + LC, medial columns+ lateral columns; MC+ PC, medial columns+ posterior columns; SLC, single lateral column; SMC, single medial column; SPC, single posterior column. Morphological associations between proximal fibular fractures and tibial plateau fractures, as classified by the CT-based three-column classification, revealed distinct patterns. Specifically, group I fractures were absent in posterior column fractures or combined lateral-posterior column injuries. Group II fractures did not occur in isolated lateral column fractures or combined medial-lateral column fractures. Group III fractures were exclusively associated with combined lateral-posterior column or three-column fractures. Logistic regression analysis utilized the "three-column" fracture type as the reference category due to its comprehensive fracture spectrum. Results indicated a significantly higher likelihood of group I fractures in isolated medial column fractures. Conversely, group II fractures occurred more frequently with combined lateral-posterior or medial-posterior column fractures compared to three-column fractures. Notably, group III fractures were more commonly associated with three-column fractures than lateral-posterior column injuries (Table 3 ).The detailed results of the logistic regression analysis are summarized in Table 4 . Table 4 The summery results of the significant dummy variables for the different fibular fracture conditions and 3d-CT tibia plateau classifications(“Enter” method) Fibula fracture condition 3d-CT tibia plateau classifications B S.E, Walds Sig. OR I SMC 1.619 0.521 9.65 0.002 5.046 II LC + PC 1.929 0.421 20.964 0 6.88 MC + PC 1.5 0.436 11.844 0.001 4.48 III LC + PC -0.934 0.422 4.898 0.027 0.393 Annotations: the reference of dummy variables is “three-column type”. 4. Discussion Recent biomechanical and clinical studies have emphasized the significance of the proximal fibula in maintaining the structural integrity and functional stability of the posterolateral corner (PLC) of the knee[ 1 – 3 , 8 ]. The proximal tibiofibular joint, a critical anatomical structure, provides lateral stability to the tibial plateau and contributes to knee joint stability; however, its involvement often complicates the management of tibial plateau fractures [ 9 ]. Although proximal fibular fractures have been classified as AO subgroup 4F1, this classification predominantly addresses fracture localization and does not sufficiently reflect the detailed morphology or mechanisms underlying these fractures[ 9 ]. Takahashi et al.[ 6 ], through anatomical dissections and computer-assisted modeling, described the proximal fibula's characteristic pyramidal anatomy, which serves as a vital insertion site for the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon. The anatomical landmarks—such as the lateral prominence, fibular styloid process, anterior and medial cortical points—are consistently identifiable on 3D-CT imaging, facilitating precise fracture characterization. In our study cohort, comminution patterns of proximal fibular fractures displayed notable variability, likely influenced by tendon and ligamentous insertions at medial, lateral, and posterior regions. In our previous study, proximal fibular fractures were classified based solely on fracture line positions observed on plain radiographs[ 1 ]. However, 3D-CT imaging in the current study revealed a more complex fracture morphology. Therefore, our expanded hypothetical classification integrates both anatomical features and radiographic fracture characteristics to better delineate injury mechanisms. Clinically, fractures classified within group I closely resemble the "arcuate fractures" described previously [ 8 ]. Such avulsion injuries typically result from varus stress mechanisms rather than direct axial loading from the tibial segment. Surgeons generally advocate operative fixation or ligament reconstruction in cases involving group I2 fractures (classic arcuate fractures) or certain comminuted group II fractures, given their direct impact on PLC stability[ 11 , 12 ]. The presence of group I fractures in isolated medial column fractures, as well as complex multi-column fractures, suggests diverse trauma mechanisms, including compound injuries and multidirectional force applications. In contrast, no cases categorized as subtype II1p(L) or II2p(L + P) were identified, nor were group II fractures observed in isolated lateral or combined medial-lateral column fractures. Our analysis suggests that comminuted proximal fibular fractures (II2p and II3p) typically result from high-energy forces initiating at the proximal tibiofibular articulation and propagating posteriorly and laterally, ultimately breaching the cortical integrity and leading to extensive concomitant tibial plateau damage. Although subtype III3 fractures were not observed in this study, this fracture pattern is typically associated with lower limb rotational injuries such as Maisonneuve fractures involving distal tibia or ankle injuries [ 11 , 12 ]. The proximal fibula's stabilizing role, mediated by interosseous and ligamentous structures, primarily resists rotational rather than direct axial forces; thus, tibial plateau fractures associated with proximal fibular fractures typically occur due to combined varus or valgus loading with rotational components, rather than simple axial compression [ 13 , 14 ]. Several limitations warrant consideration when interpreting these results. Firstly, this study was retrospective and conducted at a single trauma center, which may limit generalizability. Additionally, clinical follow-up data were limited, potentially restricting insights into functional outcomes. Moreover, patients with concurrent femoral or distal tibial injuries were excluded, possibly underestimating the complexity of proximal fibular fracture patterns. Prospective, multicenter studies with larger patient cohorts and comprehensive follow-up data are necessary to further clarify the associations and biomechanical mechanisms underlying proximal fibular fractures in the context of complex knee injuries.The detailed results of the logistic regression analysis are summarized in Table 4 . 5. Conclusion This study systematically characterized the morphological patterns of proximal fibular fractures associated with tibial plateau fractures, revealing substantial fracture heterogeneity indicative of varied traumatic mechanisms. Our findings highlight specific morphological associations between proximal fibular fractures and distinct tibial plateau fracture patterns. Further clinical studies and biomechanical analyses are warranted to clarify injury mechanisms and optimize treatment strategies for these complex fracture combinations. Declarations Declaration of interest None of the authors have any conflicts of interest related to our submitted manuscript. Author Contribution Yue Liu, Jinxia Yang,Renda Liu and Yunli He contributed equally as co-first authors. Zhi Wang and Zisheng Ai are corresponding authors, responsible for study design and manuscript oversight. All authors contributed critically to data interpretation and revisions. Acknowledgements The study was supported by the Discipline Construction Project of Characteristic Clinic of Pudong New Area Health Commission (PWYts2018-03), Research Grant for Health Science and Technology of Pudong Health and Family Planning Commission of Shanghai (Grant No. PW2020A-28), Top-notch Talent Training Program of Pudong Gongli Hospital (No. GLRb2020-04), 2024 Gusau Health Talent Research Program (GSWS2023049), the 2022 Suzhou Science and Technology and Development Project Healthcare Science and Technology Innovation Project (SKY2022168). Data Availability Data Availability: The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. References Liu Y, Zhang Y, Liang X, Shao J, Ai Z, Yang T: Relative incidence of proximal fibula fractures with tibial plateau fractures: an investigation of 354 cases . The Journal of Knee Surgery 2020, 33 (06):531-535. Zheng ZL, Yu YY, Chang HR, Liu H, Zhou HL, Zhang YZ: Establishment of classification of tibial plateau fracture associated with proximal fibular fracture . ORTHOP SURG 2019, 11 (1):97-101. Bozkurt M, Turanli S, Doral MN, Karaca S, Doğan M, Şeşen H, Basbozkurt M: The impact of proximal fibula fractures in the prognosis of tibial plateau fractures: a novel classification . Knee Surgery, Sports Traumatology, Arthroscopy 2005, 13 :323-328. Tuttle TA, Manley PA: Risk factors associated with fibular fracture after tibial plateau leveling osteotomy . VET SURG 2009, 38 (3):355-360. Van Den Bekerom MP, van Dijk NC: Is fibular fracture displacement consistent with tibiotalar displacement? Clinical Orthopaedics and Related Research® 2010, 468 (4):969-974. Takahashi H, Tajima G, Kikuchi S, Yan J, Kamei Y, Maruyama M, Sugawara A, Saigo T, Doita M: Morphology of the fibular insertion of the posterolateral corner and biceps femoris tendon . Knee Surgery, Sports Traumatology, Arthroscopy 2017, 25 :184-191. Kruckeberg BM, Cinque ME, Moatshe G, Marchetti D, DePhillipo NN, Chahla J, LaPrade RF: Proximal tibiofibular joint instability and treatment approaches: a systematic review of the literature . Arthroscopy: The Journal of Arthroscopic & Related Surgery 2017, 33 (9):1743-1751. Cohen BH, DeFroda SF, Hodax JD, Johnson D, Ware JK, Fadale PD: The arcuate fracture: a descriptive radiographic study . INJURY 2018, 49 (10):1871-1877. Wang Y, Luo C, Zhu Y, Zhai Q, Zhan Y, Qiu W, Xu Y: Updated three-column concept in surgical treatment for tibial plateau fractures – a prospective cohort study of 287 patients . INJURY 2016, 47 (7):1488-1496. Fibula . J ORTHOP TRAUMA 2018, 32 Suppl 1 :S61-S64. Inokuchi R, Jujo Y, Iwashita K, Takao M: Maisonneuve fracture: a type of ankle fracture . BMJ Case Reports 2019, 12 (11):e231961. Neto JBA, Cavalcante MLC, Neto LHP, de Lucena IF, Garrido RJ, Da Rocha PHM: Lesão variante de Maisonneuve com luxação tibiofibular proximal . Revista Brasileira de Ortopedia 2019, 54 (03):339-342. Yao X, Xu Y, Yuan J, Lv B, Fu X, Wang L, Yang S, Meng S: Classification of tibia plateau fracture according to the “ four-column and nine-segment ” . INJURY 2018, 49 (12):2275-2283. Chen P, Shen H, Wang W, Ni B, Fan Z, Lu H: The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study . J ORTHOP SURG RES 2016, 11 :1-8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6664618","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":466307471,"identity":"b40a8e09-5f9d-4cfa-88c1-871b0d3f54a1","order_by":0,"name":"Yue Liu","email":"","orcid":"","institution":"Tongji University","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Liu","suffix":""},{"id":466307472,"identity":"8e7a3b0e-1119-4d68-afb4-616b4c15b5d7","order_by":1,"name":"Jinxia Yang","email":"","orcid":"","institution":"Tongji University","correspondingAuthor":false,"prefix":"","firstName":"Jinxia","middleName":"","lastName":"Yang","suffix":""},{"id":466307473,"identity":"7d62b636-1070-4795-930a-6158ce194409","order_by":2,"name":"Renda Liu","email":"","orcid":"","institution":"School of Gongli Hospital Medical Technology, University of Shanghai for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Renda","middleName":"","lastName":"Liu","suffix":""},{"id":466307474,"identity":"24fb58f9-84d6-4424-bd65-df90e61bb6da","order_by":3,"name":"Yunli He","email":"","orcid":"","institution":"School of Gongli Hospital Medical Technology, University of Shanghai for Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Yunli","middleName":"","lastName":"He","suffix":""},{"id":466307475,"identity":"c401d895-a107-43ff-bdde-4c04c1094e02","order_by":4,"name":"Jiagi Wang","email":"","orcid":"","institution":"Shanghai Pudong New Area Gongli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiagi","middleName":"","lastName":"Wang","suffix":""},{"id":466307480,"identity":"5f9008d7-d584-47b1-ba6f-f24925fd266d","order_by":5,"name":"Zhi Wang","email":"","orcid":"","institution":"Shanghai Pudong New Area Gongli Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"","lastName":"Wang","suffix":""},{"id":466307482,"identity":"cacc5405-e692-4254-ba07-c1db48080cd9","order_by":6,"name":"Zisheng Ai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYJCCAx8qbOTALAkDEJewDsaDM86kGfOQooX5MG/LocQehKUE1PP3H39wmLfhQPp+9t7DLywKGOT4biQwfi7Ao0XiwBmDg3N33Mnt4TmXZgF0mLHkjQRm6Rn4rDnYw3Dg7ZlnuT0SOWYGQC2JG24ksDHz4NEhf5j9wQHetsPpPFAt9QS1GBxjMDgI1JIA1GL8AKglwYCQFsMzPAagQDbsOXPGDBjIEoYzzzxslsanRe788ccfgFEpz97eY/xZ4o+NPN/x5IOf8WlBBmzSEgwSQJqxgUgNwDj9+IFotaNgFIyCUTCSAABvE1EYdtGhxQAAAABJRU5ErkJggg==","orcid":"","institution":"Tongji University","correspondingAuthor":true,"prefix":"","firstName":"Zisheng","middleName":"","lastName":"Ai","suffix":""}],"badges":[],"createdAt":"2025-05-14 13:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6664618/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6664618/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84202058,"identity":"95ecc936-03de-4370-884c-20c80b91f03a","added_by":"auto","created_at":"2025-06-09 08:38:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5504429,"visible":true,"origin":"","legend":"\u003cp\u003e13 hypothetical conditions on proximal fibula fractures\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6664618/v1/901985e9ae0f37ad55a9137e.png"},{"id":84202056,"identity":"27d63266-d6b1-4d91-a458-9d34015863b6","added_by":"auto","created_at":"2025-06-09 08:38:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":778031,"visible":true,"origin":"","legend":"\u003cp\u003ethe proximal fibular structure into three columns (medial, lateral, and posterior)\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6664618/v1/6bf8c4e0d4ed68a4f5a91966.png"},{"id":85904566,"identity":"452b18ec-2d3f-4a9a-a801-5d5b32b6bbf2","added_by":"auto","created_at":"2025-07-03 03:17:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2185522,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6664618/v1/78ee2c6c-cdb8-4857-92cb-902369fd7540.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Morphological study of proximal fibular fractures with concomitant tibial plateau fractures：an investigation of 223 cases","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eProximal fibular fractures constitute a common clinical entity, presenting either as isolated injuries or in conjunction with more complex knee or ankle trauma. Despite their prevalence, these fractures have often been overlooked in clinical assessment, resulting in insufficient characterization of their radiographic patterns in current orthopedic literature[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent advances in the anatomical and biomechanical understanding of the posterolateral knee structures have underscored the clinical significance of proximal fibular fractures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe proximal fibula exhibits a distinct pyramidal anatomy, serving as an essential anatomical landmark for the fibular insertion points of key posterolateral corner (PLC) structures, including the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Given this anatomical configuration, the proximal fibula is critically involved in stabilizing the knee joint, particularly against varus loading, external rotation, and posterior tibial translation forces [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Hence, comprehensive characterization of fracture patterns in this region is clinically important to better understand injury mechanisms and optimize therapeutic strategies.\u003c/p\u003e \u003cp\u003ePrevious studies have offered valuable insights into specific fracture patterns such as arcuate fractures, correlating their radiographic features with the unique anatomy of the proximal fibula [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our prior research similarly highlighted the frequent coexistence of proximal fibular fractures with tibial plateau fractures, prompting the development of a novel radiographic classification based on fracture location as visualized on plain X-rays [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Nevertheless, three-dimensional computed tomography (3D-CT) imaging has revealed substantially greater complexity and variability in proximal fibular fracture morphologies compared with traditional radiographic assessments. Thus, further in-depth morphological studies using advanced imaging modalities are warranted.\u003c/p\u003e \u003cp\u003eThe present study addresses this knowledge gap by systematically evaluating proximal fibular fracture patterns using 3D-CT imaging. Specifically, we aimed: (1) to categorize proximal fibular fractures into defined morphological subtypes based on comprehensive 3D-CT analyses and anatomical considerations, and subsequently determine the distribution characteristics of these subtypes; (2) to investigate the associations between proximal fibular fracture morphologies and tibial plateau fracture subtypes according to the established CT-based three-column classification system. The findings of this study could facilitate a deeper understanding of knee injury patterns and serve as a reference for further clinical and biomechanical research.\u003c/p\u003e"},{"header":"2. Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design and Patient Selection\u003c/h2\u003e \u003cp\u003eThis study retrospectively analyzed clinical and imaging data from patients admitted with tibial plateau fractures to the Department of Orthopedics at Gongli Hospital, affiliated with the Second Military Medical University, from January 2011 to January 2024. Eligible cases were identified using the hospital information system (Ruijin, China) with search terms \"tibial plateau fracture\" combined with \"fibular fracture\" or \"fibular head fracture. \"The study was approved by the Institutional Review Board of Gongli Hospital, and all methods were performed in accordance with the relevant guidelines and regulations.Due to the retrospective nature of the study, the need for informed consent was waived by the Institutional Review Board of Gongli Hospital.\u003c/p\u003e \u003cp\u003eExclusion criteria included:\u003c/p\u003e \u003cp\u003e(1) Fibular hairline fractures or displaced segments less than 2 mm;\u003c/p\u003e \u003cp\u003e(2) Pathological fractures secondary to severe osteoporosis or tumor involvement;\u003c/p\u003e \u003cp\u003e(3) Concomitant fractures of the femur or distal tibia;\u003c/p\u003e \u003cp\u003e(4) Unsatisfactory radiographic or computed tomography (CT) imaging, including poor patient positioning, image quality, or incomplete radiologic documentation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Imaging and Data Acquisition\u003c/h2\u003e \u003cp\u003eRadiographic data, including standard anteroposterior (AP) and lateral X-rays, as well as three-dimensional computed tomography (3D-CT) scans, were digitally retrieved from the hospital's picture archiving and communication system (PACS, Centricity; Jinshida, China).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Morphological Classification of Proximal Fibular Fractures\u003c/h2\u003e \u003cp\u003eBased on fracture line characteristics and comminution patterns observed on 3D-CT scans, proximal fibular fractures concomitant with tibial plateau fractures were categorized into 13 predefined morphological conditions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These conditions were classified into three main groups:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGroup I (Avulsion Fractures): Horizontal fracture line primarily indicating ligamentous avulsion.\u003c/p\u003e \u003cp\u003eI1: Small avulsion fractures limited to the fibular styloid.\u003c/p\u003e \u003cp\u003eI2: Superior cortical rim avulsions involving the arcuate ligament complex (classic \"arcuate fractures\").\u003c/p\u003e \u003cp\u003eI3: Fractures extending through metaphyseal bone without comminution.\u003c/p\u003e \u003cp\u003eGroup II (Cleavage and Comminution Fractures): Cleavage and comminution fractures of the fibular head, subdivided according to involvement of anatomical columns based on the model described by Takahashi et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e](medial, lateral, posterior columns; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eII1p: Single-column fracture (M, L, or P);\u003c/p\u003e \u003cp\u003eII2p: Two-column fractures (M\u0026thinsp;+\u0026thinsp;L, M\u0026thinsp;+\u0026thinsp;P, or L\u0026thinsp;+\u0026thinsp;P);\u003c/p\u003e \u003cp\u003eII3p: Three-column fractures involving medial, lateral, and posterior aspects.\u003c/p\u003e \u003cp\u003eGroup III (Fibular Neck or Shaft Fractures): Fractures distal to the head involving the fibular neck or proximal shaft region:\u003c/p\u003e \u003cp\u003eIII1: Oblique fracture oriented from superomedial to inferolateral direction.\u003c/p\u003e \u003cp\u003eIII2: Horizontal or extensively comminuted fractures.\u003c/p\u003e \u003cp\u003eIII3: Oblique fracture oriented from inferomedial to superolateral direction.\u003c/p\u003e \u003cp\u003eTibial plateau fractures were concurrently classified using the established CT-based three-column classification system described by Luo et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Reliability Assessment and Observers\u003c/h2\u003e \u003cp\u003eTo evaluate inter-observer reliability, two independent observers with differing expertise were recruited: an orthopedic trauma surgeon (Observer 1) with extensive clinical experience in fracture management, and a musculoskeletal radiologist (Observer 2) experienced in fracture imaging interpretation. Both observers were blinded to patient clinical outcomes and had no conflicts of interest.\u003c/p\u003e \u003cp\u003ePrior to evaluation, each observer was provided with detailed schematic illustrations and written instructions regarding the morphological classification system. In cases of disagreement, a consensus was reached through collaborative review and discussion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Analysis\u003c/h2\u003e \u003cp\u003eData were initially collected and organized using Excel spreadsheets (Microsoft Corp., Redmond, WA), followed by independent verification for accuracy, completeness, and logical consistency. Verified data were then imported into Statistical Product and Service Solutions (SPSS, Version 20.0; SPSS Inc., Chicago, IL) for further analysis.\u003c/p\u003e \u003cp\u003eDescriptive statistical methods were employed to summarize the distribution of fibular fracture morphologies. Logistic regression analyses were subsequently conducted to determine associations between specific proximal fibular fracture patterns and the tibial plateau fracture subtypes according to the three-column classification system.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eFrom January 2011 to January 2024, a total of 479 patient records were initially retrieved using the keyword \"tibial plateau fracture.\" Following further screening with additional keywords (\"fibular fracture\" or \"fibular head fracture\"), 285 records remained. After applying inclusion and exclusion criteria, 223 eligible cases (123 males, 100 females) were ultimately included in the analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e123 (55.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100 (44.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116 (52.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107 (48.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury types\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFall from bicycle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (23.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSlip down\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54 (24.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong these cases, proximal fibular fractures were categorized into group I (avulsion fractures, n\u0026thinsp;=\u0026thinsp;63, 28.3%), group II (cleavage and comminution fractures, n\u0026thinsp;=\u0026thinsp;121, 54.3%), and group III (neck or proximal shaft fractures, n\u0026thinsp;=\u0026thinsp;39, 17.4%). Within group II, the most frequent subtype was II3p (three-part comminution), occurring in 62 patients (51.3%). Subtypes II1p(L), II2p(L\u0026thinsp;+\u0026thinsp;P), and III3 were not identified within our study cohort (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of 223 proximal fibula fractures according to the 3 groups, 13 hypothetical conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c10\" namest=\"c4\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eII1p\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eII2p\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eII3p\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIII1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIII2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eIII3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eII1p(M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eII1p(P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eII1p(L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eII2p(M\u0026thinsp;+\u0026thinsp;L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eII2p(M\u0026thinsp;+\u0026thinsp;P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eII2p(L\u0026thinsp;+\u0026thinsp;P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e63 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c10\" namest=\"c4\"\u003e \u003cp\u003e121 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e39 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e: Distribution of proximal fibula fractures according to hypothetical conditions in the CT-based three-column tibial plateau fracture classification [deleted II1p(L), II2p(L+P), and III3 subgroups]\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ehypothetical conditions for proximal fibular fractures\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCT-based three-column: n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003eI1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003eI2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eI3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003eII1p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003eII2p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eII3p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eIII1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eIII2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eII1p (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eII1p (P)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eII2p (M+L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eII2p (M+P)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSMC n=21\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e9.42%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSLC n=17,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e7.62%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPC n=12,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e5.38%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMC + LC n=4,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e1.79%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMC + PC n=38,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e17.04%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLC + PC n=53,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e23.77%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ethree columns n=78,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003e34.98%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: CT, computed tomography; LC+ PC, lateral columns+ posterior columns; MC + LC, medial columns+ lateral columns; MC+ PC, medial columns+ posterior columns; SLC, single lateral column; SMC, single medial column; SPC, single posterior column.\u0026nbsp;\u003c/p\u003e \u003cp\u003eMorphological associations between proximal fibular fractures and tibial plateau fractures, as classified by the CT-based three-column classification, revealed distinct patterns. Specifically, group I fractures were absent in posterior column fractures or combined lateral-posterior column injuries. Group II fractures did not occur in isolated lateral column fractures or combined medial-lateral column fractures. Group III fractures were exclusively associated with combined lateral-posterior column or three-column fractures.\u003c/p\u003e \u003cp\u003eLogistic regression analysis utilized the \"three-column\" fracture type as the reference category due to its comprehensive fracture spectrum. Results indicated a significantly higher likelihood of group I fractures in isolated medial column fractures. Conversely, group II fractures occurred more frequently with combined lateral-posterior or medial-posterior column fractures compared to three-column fractures. Notably, group III fractures were more commonly associated with three-column fractures than lateral-posterior column injuries (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).The detailed results of the logistic regression analysis are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe summery results of the significant dummy variables for the different fibular fracture conditions and 3d-CT tibia plateau classifications(\u0026ldquo;Enter\u0026rdquo; method)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFibula fracture condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3d-CT tibia plateau classifications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS.E,\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWalds\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSig.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSMC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.619\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e 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align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLC\u0026thinsp;+\u0026thinsp;PC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.898\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAnnotations: the reference of dummy variables is \u0026ldquo;three-column type\u0026rdquo;.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eRecent biomechanical and clinical studies have emphasized the significance of the proximal fibula in maintaining the structural integrity and functional stability of the posterolateral corner (PLC) of the knee[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The proximal tibiofibular joint, a critical anatomical structure, provides lateral stability to the tibial plateau and contributes to knee joint stability; however, its involvement often complicates the management of tibial plateau fractures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although proximal fibular fractures have been classified as AO subgroup 4F1, this classification predominantly addresses fracture localization and does not sufficiently reflect the detailed morphology or mechanisms underlying these fractures[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTakahashi et al.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], through anatomical dissections and computer-assisted modeling, described the proximal fibula's characteristic pyramidal anatomy, which serves as a vital insertion site for the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon. The anatomical landmarks\u0026mdash;such as the lateral prominence, fibular styloid process, anterior and medial cortical points\u0026mdash;are consistently identifiable on 3D-CT imaging, facilitating precise fracture characterization. In our study cohort, comminution patterns of proximal fibular fractures displayed notable variability, likely influenced by tendon and ligamentous insertions at medial, lateral, and posterior regions.\u003c/p\u003e \u003cp\u003eIn our previous study, proximal fibular fractures were classified based solely on fracture line positions observed on plain radiographs[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, 3D-CT imaging in the current study revealed a more complex fracture morphology. Therefore, our expanded hypothetical classification integrates both anatomical features and radiographic fracture characteristics to better delineate injury mechanisms.\u003c/p\u003e \u003cp\u003eClinically, fractures classified within group I closely resemble the \"arcuate fractures\" described previously [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Such avulsion injuries typically result from varus stress mechanisms rather than direct axial loading from the tibial segment. Surgeons generally advocate operative fixation or ligament reconstruction in cases involving group I2 fractures (classic arcuate fractures) or certain comminuted group II fractures, given their direct impact on PLC stability[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The presence of group I fractures in isolated medial column fractures, as well as complex multi-column fractures, suggests diverse trauma mechanisms, including compound injuries and multidirectional force applications.\u003c/p\u003e \u003cp\u003eIn contrast, no cases categorized as subtype II1p(L) or II2p(L\u0026thinsp;+\u0026thinsp;P) were identified, nor were group II fractures observed in isolated lateral or combined medial-lateral column fractures. Our analysis suggests that comminuted proximal fibular fractures (II2p and II3p) typically result from high-energy forces initiating at the proximal tibiofibular articulation and propagating posteriorly and laterally, ultimately breaching the cortical integrity and leading to extensive concomitant tibial plateau damage.\u003c/p\u003e \u003cp\u003eAlthough subtype III3 fractures were not observed in this study, this fracture pattern is typically associated with lower limb rotational injuries such as Maisonneuve fractures involving distal tibia or ankle injuries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The proximal fibula's stabilizing role, mediated by interosseous and ligamentous structures, primarily resists rotational rather than direct axial forces; thus, tibial plateau fractures associated with proximal fibular fractures typically occur due to combined varus or valgus loading with rotational components, rather than simple axial compression [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral limitations warrant consideration when interpreting these results. Firstly, this study was retrospective and conducted at a single trauma center, which may limit generalizability. Additionally, clinical follow-up data were limited, potentially restricting insights into functional outcomes. Moreover, patients with concurrent femoral or distal tibial injuries were excluded, possibly underestimating the complexity of proximal fibular fracture patterns. Prospective, multicenter studies with larger patient cohorts and comprehensive follow-up data are necessary to further clarify the associations and biomechanical mechanisms underlying proximal fibular fractures in the context of complex knee injuries.The detailed results of the logistic regression analysis are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study systematically characterized the morphological patterns of proximal fibular fractures associated with tibial plateau fractures, revealing substantial fracture heterogeneity indicative of varied traumatic mechanisms. Our findings highlight specific morphological associations between proximal fibular fractures and distinct tibial plateau fracture patterns. Further clinical studies and biomechanical analyses are warranted to clarify injury mechanisms and optimize treatment strategies for these complex fracture combinations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of interest\u003c/h2\u003e \u003cp\u003eNone of the authors have any conflicts of interest related to our submitted manuscript.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYue Liu, Jinxia Yang,Renda Liu and Yunli He contributed equally as co-first authors. Zhi Wang and Zisheng Ai are corresponding authors, responsible for study design and manuscript oversight. All authors contributed critically to data interpretation and revisions.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe study was supported by the Discipline Construction Project of Characteristic Clinic of Pudong New Area Health Commission (PWYts2018-03), Research Grant for Health Science and Technology of Pudong Health and Family Planning Commission of Shanghai (Grant No. PW2020A-28), Top-notch Talent Training Program of Pudong Gongli Hospital (No. GLRb2020-04), 2024 Gusau Health Talent Research Program (GSWS2023049), the 2022 Suzhou Science and Technology and Development Project Healthcare Science and Technology Innovation Project (SKY2022168).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData Availability: The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLiu Y, Zhang Y, Liang X, Shao J, Ai Z, Yang T: \u003cstrong\u003eRelative incidence of proximal fibula fractures with tibial plateau fractures: an investigation of 354 cases\u003c/strong\u003e. \u003cem\u003eThe Journal of Knee Surgery\u003c/em\u003e 2020, \u003cstrong\u003e33\u003c/strong\u003e(06):531-535.\u003c/li\u003e\n\u003cli\u003eZheng ZL, Yu YY, Chang HR, Liu H, Zhou HL, Zhang YZ: \u003cstrong\u003eEstablishment of classification of tibial plateau fracture associated with proximal fibular fracture\u003c/strong\u003e. \u003cem\u003eORTHOP SURG\u003c/em\u003e 2019, \u003cstrong\u003e11\u003c/strong\u003e(1):97-101.\u003c/li\u003e\n\u003cli\u003eBozkurt M, Turanli S, Doral MN, Karaca S, Doğan M, Şeşen H, Basbozkurt M: \u003cstrong\u003eThe impact of proximal fibula fractures in the prognosis of tibial plateau fractures: a novel classification\u003c/strong\u003e. \u003cem\u003eKnee Surgery, Sports Traumatology, Arthroscopy\u003c/em\u003e 2005, \u003cstrong\u003e13\u003c/strong\u003e:323-328.\u003c/li\u003e\n\u003cli\u003eTuttle TA, Manley PA: \u003cstrong\u003eRisk factors associated with fibular fracture after tibial plateau leveling osteotomy\u003c/strong\u003e. \u003cem\u003eVET SURG\u003c/em\u003e 2009, \u003cstrong\u003e38\u003c/strong\u003e(3):355-360.\u003c/li\u003e\n\u003cli\u003eVan Den Bekerom MP, van Dijk NC: \u003cstrong\u003eIs fibular fracture displacement consistent with tibiotalar displacement?\u003c/strong\u003e \u003cem\u003eClinical Orthopaedics and Related Research\u0026reg;\u003c/em\u003e 2010, \u003cstrong\u003e468\u003c/strong\u003e(4):969-974.\u003c/li\u003e\n\u003cli\u003eTakahashi H, Tajima G, Kikuchi S, Yan J, Kamei Y, Maruyama M, Sugawara A, Saigo T, Doita M: \u003cstrong\u003eMorphology of the fibular insertion of the posterolateral corner and biceps femoris tendon\u003c/strong\u003e. \u003cem\u003eKnee Surgery, Sports Traumatology, Arthroscopy\u003c/em\u003e 2017, \u003cstrong\u003e25\u003c/strong\u003e:184-191.\u003c/li\u003e\n\u003cli\u003eKruckeberg BM, Cinque ME, Moatshe G, Marchetti D, DePhillipo NN, Chahla J, LaPrade RF: \u003cstrong\u003eProximal tibiofibular joint instability and treatment approaches: a systematic review of the literature\u003c/strong\u003e. \u003cem\u003eArthroscopy: The Journal of Arthroscopic \u0026amp; Related Surgery\u003c/em\u003e 2017, \u003cstrong\u003e33\u003c/strong\u003e(9):1743-1751.\u003c/li\u003e\n\u003cli\u003eCohen BH, DeFroda SF, Hodax JD, Johnson D, Ware JK, Fadale PD: \u003cstrong\u003eThe arcuate fracture: a descriptive radiographic study\u003c/strong\u003e. \u003cem\u003eINJURY\u003c/em\u003e 2018, \u003cstrong\u003e49\u003c/strong\u003e(10):1871-1877.\u003c/li\u003e\n\u003cli\u003eWang Y, Luo C, Zhu Y, Zhai Q, Zhan Y, Qiu W, Xu Y: \u003cstrong\u003eUpdated three-column concept in surgical treatment for tibial plateau fractures\u003c/strong\u003e\u003cstrong\u003e\u0026ndash;\u003c/strong\u003e\u003cstrong\u003ea prospective cohort study of 287 patients\u003c/strong\u003e. \u003cem\u003eINJURY\u003c/em\u003e 2016, \u003cstrong\u003e47\u003c/strong\u003e(7):1488-1496.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFibula\u003c/strong\u003e. \u003cem\u003eJ ORTHOP TRAUMA\u003c/em\u003e 2018, \u003cstrong\u003e32 Suppl 1\u003c/strong\u003e:S61-S64.\u003c/li\u003e\n\u003cli\u003eInokuchi R, Jujo Y, Iwashita K, Takao M: \u003cstrong\u003eMaisonneuve fracture: a type of ankle fracture\u003c/strong\u003e. \u003cem\u003eBMJ Case Reports\u003c/em\u003e 2019, \u003cstrong\u003e12\u003c/strong\u003e(11):e231961.\u003c/li\u003e\n\u003cli\u003eNeto JBA, Cavalcante MLC, Neto LHP, de Lucena IF, Garrido RJ, Da Rocha PHM: \u003cstrong\u003eLes\u0026atilde;o variante de Maisonneuve com luxa\u0026ccedil;\u0026atilde;o tibiofibular proximal\u003c/strong\u003e. \u003cem\u003eRevista Brasileira de Ortopedia\u003c/em\u003e 2019, \u003cstrong\u003e54\u003c/strong\u003e(03):339-342.\u003c/li\u003e\n\u003cli\u003eYao X, Xu Y, Yuan J, Lv B, Fu X, Wang L, Yang S, Meng S: \u003cstrong\u003eClassification of tibia plateau fracture according to the \u003c/strong\u003e\u003cstrong\u003e\u0026ldquo;\u003c/strong\u003e\u003cstrong\u003efour-column and nine-segment\u003c/strong\u003e\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e. \u003cem\u003eINJURY\u003c/em\u003e 2018, \u003cstrong\u003e49\u003c/strong\u003e(12):2275-2283.\u003c/li\u003e\n\u003cli\u003eChen P, Shen H, Wang W, Ni B, Fan Z, Lu H: \u003cstrong\u003eThe morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study\u003c/strong\u003e. \u003cem\u003eJ ORTHOP SURG RES\u003c/em\u003e 2016, \u003cstrong\u003e11\u003c/strong\u003e:1-8.\u003cstrong\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tibial plateau fracture, proximal fibula fracture, computed tomography, posterolateral corner, classification, CT-based three-column classification system","lastPublishedDoi":"10.21203/rs.3.rs-6664618/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6664618/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to systematically characterize the morphological patterns of proximal fibular fractures occurring concurrently with tibial plateau fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData were retrospectively collected from a Level-1 trauma center between January 2011 and January 2024 by querying hospital information and picture archiving and communication systems with keywords \"tibial plateau fracture\" and \"fibular fracture\" or \"fibular head fracture\". Radiographic morphology was evaluated using standard anteroposterior radiographs and three-dimensional computed tomography (3D-CT), categorizing proximal fibular fractures into 13 predefined morphological patterns. Descriptive data, including fracture location, number of fragments, and degree of displacement, were recorded and classified. The distribution patterns of proximal fibular fractures were further correlated with the tibial plateau fractures, categorized according to the CT-based three-column classification system. Logistic regression analysis was conducted to identify the associations between specific tibial plateau fracture subtypes and proximal fibular fracture patterns.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 223 eligible patients (123 males) were included in the analysis. Group I, II, and III proximal fibular fractures were observed in 63 (28.3%), 121 (54.3%), and 39 (17.4%) patients, respectively. Within group II, subtype II3p was the predominant fracture pattern, occurring in 62 patients (51.3%). Subtypes II1p(L), II2p(L\u0026thinsp;+\u0026thinsp;P), and III3 were not identified in the cohort. Group I fractures did not occur in posterior column or combined lateral and posterior column fractures. Group II fractures were absent in isolated lateral column or combined medial and lateral column fractures. Group III fractures exclusively presented with combined lateral and posterior column or three-column fractures. Logistic regression indicated that group I proximal fibular fractures were significantly more associated with isolated medial column tibial plateau fractures, whereas group II fractures were significantly associated with lateral-posterior and medial-posterior column fractures compared to three-column fractures. Conversely, group III proximal fibular fractures were significantly more common with three-column fractures than with lateral-posterior column fractures.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe morphological diversity observed in proximal fibular fractures underscores the complexity and heterogeneity of concomitant tibial plateau fractures. Further clinical and biomechanical investigations are warranted to elucidate the pathomechanics underlying comminuted fibular fractures associated with tibial plateau injuries.\u003c/p\u003e","manuscriptTitle":"Morphological study of proximal fibular fractures with concomitant tibial plateau fractures：an investigation of 223 cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 08:38:00","doi":"10.21203/rs.3.rs-6664618/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9c35316-5c21-4dbd-8653-302a7b2b7b39","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49504355,"name":"Health sciences/Medical research"},{"id":49504356,"name":"Health sciences/Medical research/Epidemiology"},{"id":49504357,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2025-07-03T03:08:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 08:38:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6664618","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6664618","identity":"rs-6664618","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}