Fibular Artery

Introduction

Introduction to the Fibular Artery

The fibular artery, also known as the peroneal artery, is the largest and most important branch of the posterior tibial artery. It arises in the upper part of the posterior compartment of the leg and descends along the medial crest of the fibula, supplying the deep posterior compartment muscles, the lateral compartment (via perforating branches), and the fibula itself. It is a critical vessel for collateral circulation around the ankle and foot, especially in patients with peripheral arterial disease. The fibular artery terminates as the lateral calcaneal branches, contributing to the vascular network of the heel. Its size and role in distal perfusion make it a key target for surgical revascularization procedures, and its relationship to the fibula is essential in orthopaedic and flap surgeries.

Study

1. Origin

The fibular artery arises from the posterior tibial artery approximately 2.5–3 cm distal to the lower border of the popliteus muscle, which is the level of the tendinous arch of the soleus. In some individuals, it may originate directly from the popliteal artery or from the anterior tibial artery, but these are less common variations. The point of origin is typically at the level of the proximal tibiofibular joint. After its origin, it passes obliquely toward the fibula.

2. Course and Relations

From its origin, the fibular artery runs inferolaterally toward the fibula, then descends vertically along the medial crest of the fibula, within the deep posterior compartment. It is covered throughout most of its course by the flexor hallucis longus muscle, which overlies it. The artery lies between the tibialis posterior (anterior) and the flexor hallucis longus (posterior), directly on the fibula or the interosseous membrane. Medially, it is related to the posterior tibial artery and tibial nerve, from which it diverges as it descends.

In the distal third of the leg, the fibular artery lies close to the interosseous membrane and gives off its perforating branch. At the level of the ankle, it passes behind the inferior tibiofibular syndesmosis and divides into its terminal branches, the lateral calcaneal arteries, which supply the lateral aspect of the heel. Accompanying the artery throughout its course are the venae comitantes of the fibular artery.

3. Branches

The fibular artery gives off several important branches: (1) Muscular branches – supply the deep posterior compartment muscles: flexor hallucis longus, tibialis posterior, and the soleus. (2) Perforating branches – pierce the posterior intermuscular septum to supply the fibularis longus and brevis muscles in the lateral compartment. The main perforating branch passes through the interosseous membrane about 5 cm above the lateral malleolus to enter the anterior compartment, where it anastomoses with the lateral malleolar branch of the anterior tibial artery. (3) Nutrient artery to the fibula – enters the nutrient foramen on the medial aspect of the fibula. (4) Communicating branch – a transverse branch that joins the posterior tibial artery in the distal leg, providing collateral flow. (5) Lateral calcaneal branches – the terminal branches that supply the lateral heel, anastomosing with the lateral tarsal artery and the medial calcaneal branches. (6) Malleolar branches – contribute to the lateral malleolar network around the ankle.

4. Anastomoses and Collateral Circulation

The fibular artery plays a crucial role in the collateral circulation of the leg and foot, particularly when the anterior or posterior tibial arteries are occluded. The perforating branch connects with the lateral malleolar branch of the anterior tibial artery, providing an alternative route to the dorsalis pedis artery. The communicating branch links the fibular artery to the posterior tibial artery, ensuring distal flow if the posterior tibial artery is compromised proximally. The lateral calcaneal branches anastomose with the lateral tarsal artery (from dorsalis pedis) and the medial calcaneal branches, forming the calcaneal anastomosis, which is vital for heel perfusion. Because of these robust connections, the fibular artery is often the vessel that remains patent in advanced peripheral arterial disease, making it a critical target for distal bypass grafts.

5. Clinical Relevance

Peripheral arterial disease (PAD): In patients with tibial artery occlusive disease, the fibular artery often remains the single continuous vessel to the foot. It is the preferred distal target for femorofibular or popliteal-fibular bypass grafts. Assessment of its patency via angiography or duplex ultrasound is essential in planning limb salvage procedures.

Fibular free flap: The fibula, with its nutrient artery (fibular artery), is commonly harvested as a vascularized bone graft for mandibular or long bone reconstruction. The vascular pedicle includes the fibular artery and its venae comitantes. Preoperative imaging (CT angiography) is required to ensure the foot's blood supply will not be compromised after sacrifice, particularly by confirming the presence of a patent posterior tibial artery and adequate collateral circulation.

Fractures: Fractures of the fibula, especially high-energy injuries or those associated with syndesmotic disruption, can damage the fibular artery. Since the artery runs close to the bone, vascular injury may result in significant hemorrhage, pseudoaneurysm, or compartment syndrome. In Gustilo-Anderson type IIIB and IIIC open fractures, the fibular artery may be disrupted, necessitating vascular repair or bypass.

Ankle fractures: In ankle fracture-dislocations, the perforating branch of the fibular artery (just above the syndesmosis) may be torn, leading to hematoma and impaired collateral flow to the foot. The lateral calcaneal branches are at risk during surgical approaches to the lateral calcaneus.

Doppler assessment: The fibular artery can be insonated with a Doppler probe placed posterior to the lateral malleolus. In some individuals, it may be the only artery supplying the foot when both the anterior and posterior tibial arteries are diseased.

Summary

Summary of the Fibular Artery

The fibular artery is a branch of the posterior tibial artery, arising just distal to the popliteus and descending along the fibula. It supplies the deep posterior and lateral compartments, the fibula, and provides critical collateral pathways to the foot via its perforating and communicating branches. Its terminal lateral calcaneal branches supply the lateral heel. It is of paramount importance in vascular bypass surgery and is the pedicle for the fibular free flap. The artery's relationship to the fibula makes it susceptible to injury in fractures, and its patency is crucial in limb salvage for peripheral arterial disease.