What is the treatment for a medium malleolar fracture?

Treatment of Medium Malleolar Fractures

The standard treatment for medium malleolar fractures is initial radiographic assessment followed by appropriate surgical fixation if the fracture is displaced, as this approach provides the best outcomes for morbidity, mortality, and quality of life.

Initial Assessment and Diagnosis

1. Radiographic Evaluation:

   • Three standard views are required: anteroposterior, lateral, and mortise views 1
   • Weight-bearing radiographs (if possible) provide critical information about fracture stability 1
   • A medial clear space of <4 mm confirms stability 1

2. Stability Assessment:

   • Increased risk of instability is associated with:
     • Medial tenderness, bruising, or swelling
     • Fibular fracture above the syndesmosis
     • Bi- or trimalleolar fractures
     • Open fracture
     • High-energy fracture injury 1

Treatment Algorithm

Non-Surgical Management

• Reserved for non-displaced malleolar fractures
• Immobilization with a total contact cast (TCC) or non-removable knee-high device 1
• Regular follow-up radiographs to ensure the fracture remains non-displaced

Surgical Management

• Indicated for:

  • Displaced fractures
  • Unstable fractures (medial clear space >4 mm)
  • Fractures with articular incongruity
  • Bi- or trimalleolar fractures

• Surgical Technique:

  • Single screw fixation is equally effective as double screw fixation for medial malleolar fractures 2
  • Anatomic reduction is crucial for optimal outcomes 3
  • Internal fixation using standard AO techniques is recommended 3

Special Considerations

Inspection of Articular Surface

• During surgery, inspection of the entire talar dome is essential as 49% of patients with malleolar fractures have associated chondral injuries 3
• Patients with talar dome chondral injuries have significantly poorer functional outcomes and more complaints of pain 3

Postoperative Care

• Protected weight-bearing for 6-12 weeks depending on fracture complexity and stability of fixation
• Regular radiographic follow-up at 2 weeks, 6 weeks, 3 months, and 6 months to assess healing

Complications to Monitor

• Posttraumatic osteoarthritis is significantly associated with:
  • Poor clinical results
  • Bimalleolar fractures
  • Unsatisfactory surgical reduction 4
• Persistent ankle pain despite anatomic reduction may be due to unrecognized cartilage injuries 3

Outcomes

• Excellent and good results are achieved in most unimalleolar fractures
• Bimalleolar fractures have significantly worse outcomes 4
• The presence of a large bony fragment or dislocation significantly affects the final outcome 4

Pitfalls to Avoid

1. Delayed diagnosis: Especially in stress fractures of the medial malleolus, which require early MRI for proper identification 5
2. Inadequate reduction: Unsatisfactory surgical reduction leads to poor outcomes and posttraumatic osteoarthritis 4
3. Missing associated injuries: Failure to inspect the talar dome for chondral injuries during surgery 3
4. Varus malalignment: This increases the risk of postoperative fractures and complications 6

By following this treatment approach with careful attention to anatomic reduction and fixation, most patients with medium malleolar fractures can achieve good functional outcomes and return to pre-injury activities.