How to manage a left malleolar fracture?

Management of Left Malleolar Fracture

The optimal management of a left malleolar fracture requires a balanced approach between operative and non-operative treatment based on fracture type, stability, and displacement, with surgical fixation being preferred for most displaced fractures to reduce the risk of post-traumatic arthritis and improve functional outcomes. 1, 2

Initial Assessment and Classification

• Obtain bilateral foot and ankle X-rays including:

  • Anteroposterior, medial oblique, and lateral projections for the foot
  • Anteroposterior, mortise, and lateral projections for the ankle 3

• Classify the fracture using either:

  • Weber classification (based on level of fibular fracture relative to syndesmosis)
  • Lauge-Hansen classification (based on mechanism of injury) 2

• Assess for:

  • Fracture displacement and stability
  • Syndesmotic injury
  • Medial malleolar involvement
  • Posterior malleolar fragment
  • Associated soft tissue injury 2

Treatment Algorithm

Non-operative Management

Indicated for:

• Stable, non-displaced fractures
• Patients with significant comorbidities making surgery high-risk

Treatment approach:

1. Immobilization with cast or boot walker
2. PRICE protocol (protection, rest, ice, compression, elevation) 3
3. Non-weight bearing for 4-6 weeks
4. Serial radiographs to ensure no displacement occurs

Surgical Management

Indicated for:

• Displaced fractures
• Unstable fractures
• Fracture-dislocations
• Significant soft tissue injury
• Open fractures

Lateral Malleolus Fixation Options:

1. Plate and screw fixation (standard approach):

   • Anatomical reduction is critical
   • Ensures proper length and rotation of fibula 4

2. Intramedullary fixation (alternative approach):

   • Viable for most fibular fracture patterns
   • More soft-tissue friendly
   • Similar healing times to plate fixation 5

Medial Malleolus Fixation:

• Typically with screws or tension-band wiring
• Critical to assess deep deltoid ligament integrity 2

Syndesmotic Injury:

• Requires accurate assessment and appropriate fixation if unstable
• May need syndesmotic screws or suture button devices 2

Posterior Malleolus:

• Consider fixation if fragment is large (>25% of articular surface) or if ankle is unstable after fixation of other components 2

Postoperative Care

1. Immobilization:

   • Initial cast or splint for 2 weeks until wound healing
   • Transition to removable boot walker 1

2. Weight-bearing progression:

   • Non-weight bearing for 4-6 weeks
   • Progressive weight bearing based on fracture healing 1

3. Rehabilitation:

   • Early physical therapy for range of motion exercises
   • Strengthening exercises once fracture healing is evident
   • Balance training and fall prevention 1

4. Pain management:

   • NSAIDs for pain and inflammation control
   • Consider short-term opioids for severe pain 3

5. Follow-up:

   • Regular radiographic assessment to monitor healing
   • Clinical evaluation for swelling, pain, and function 1

Outcomes and Complications

• Surgical treatment generally yields better outcomes than conservative management for displaced fractures 6

• Potential complications:

  • Post-traumatic arthritis (more common with inadequate reduction)
  • Malunion or nonunion
  • Infection
  • Chronic pain (occurs in approximately 20% of patients) 3

• Poor prognostic indicators:

  • Bimalleolar fractures (worse outcomes than unimalleolar)
  • Inadequate reduction of lateral malleolus
  • Residual talar tilt
  • Open fractures
  • Comminuted fractures 7, 4

Critical Points for Success

• The lateral malleolus is the key to anatomical reduction in bimalleolar fractures - accurate reduction here ensures proper talar position 4

• Anatomical reduction is more important than the specific fixation method used 2

• Early mobilization and rehabilitation improve functional outcomes 1

• Consider patient factors (age, bone quality, activity level) when selecting treatment approach 1