From the Guidelines
For a remote medial malleolus avulsion injury, surgery is the usual treatment, but simple immobilization is appropriate when fracture fragments are small, nonarticular, or minimally displaced. A medial malleolus avulsion injury occurs when a fragment of bone is pulled away from the medial malleolus by an attached ligament, typically the deltoid ligament. The diagnosis is based on a history of trauma and focal pain on palpation, and is confirmed with radiographic studies 1. Treatment depends on the size of the fragment and displacement.
Key Considerations
- For small, non-displaced avulsion fractures, conservative management is recommended with a walking boot or cast for 4-6 weeks, non-weight bearing initially for 1-2 weeks, followed by progressive weight bearing as tolerated.
- Pain control can be achieved with NSAIDs like ibuprofen or naproxen for 5-7 days.
- Apply ice for 15-20 minutes every 2-3 hours during the first 48-72 hours to reduce swelling.
- Larger fragments or displaced fragments typically require surgical fixation with screws or tension band wiring to restore ankle stability and prevent post-traumatic arthritis.
Treatment Approach
The goal of treatment is to restore ankle stability, prevent post-traumatic arthritis, and promote complete healing. Physical therapy should begin after immobilization to restore range of motion, strength, and proprioception. Complete healing typically takes 6-12 weeks depending on fracture severity, patient age, and compliance with treatment. It is essential to prioritize treatment based on the size and displacement of the fracture fragment to ensure optimal outcomes and minimize morbidity, mortality, and impact on quality of life.
From the Research
Remote Medial Malleolus Avulsion Injury
- A remote medial malleolus avulsion injury can be a complex condition to manage, especially in pediatric patients who are still growing 2.
- The treatment of isolated medial malleolar fractures is still a topic of debate, with some studies suggesting that conservative treatment may be safe for fractures displaced ≤2 mm, while others recommend surgical intervention for more displaced fractures 3.
- Surgical techniques for medial malleolar reconstruction have been described, including the use of iliac crest autograft and distal fibula osteotomy and fixation 2.
- Biomechanical studies have compared different fixation techniques for medial malleolar fractures, including bicortical screw fixation, unicortical screw fixation, and tension-band fixation using stainless steel wire or FiberWire suture 4.
- Clinical studies have compared the outcomes of open reduction internal fixation (ORIF) and percutaneous fixation for medial malleolar fractures, with ORIF resulting in a higher rate of fracture healing at 8 weeks 5.
- The use of headless compression screws has been evaluated as a fixation method for isolated medial malleolar fractures, with promising results in terms of clinical and radiologic outcomes 6.
- The choice of treatment for a remote medial malleolus avulsion injury may depend on various factors, including the patient's age, fracture displacement, and overall health status 2, 3.
- Further research is needed to determine the optimal treatment approach for remote medial malleolus avulsion injuries, particularly in pediatric patients 2, 3.