What is the appropriate treatment for a right medial malleolus injury?

Treatment of Right Medial Malleolus Injury

The appropriate treatment for a right medial malleolus injury depends on whether it's a fracture or a sprain, with radiographic evaluation guided by the Ottawa Ankle Rules being the essential first step in management. 1

Initial Assessment and Imaging

Ottawa Ankle Rules (OAR)

Apply the OAR to determine if radiographs are necessary:

• Inability to bear weight immediately after injury OR
• Point tenderness over the medial malleolus, posterior edge/inferior tip of lateral malleolus, talus, or calcaneus OR
• Inability to ambulate for 4 steps in the emergency department 1

Imaging Recommendations

• If OAR positive: Obtain ankle radiographs
• If OAR negative: Imaging is usually not appropriate
• For persistent pain (>1 week but <3 weeks) with negative initial radiographs: MRI or CT without contrast 1
• For radiographs showing fracture: CT or MRI without contrast for further evaluation 1

Treatment Algorithm

1. For Medial Malleolus Fractures

Non-displaced or minimally displaced fractures:

• Cast immobilization for 4-6 weeks
• Progressive weight bearing as tolerated
• Monitor for healing with follow-up radiographs

Displaced fractures:

• Surgical fixation with internal fixation techniques:
  • Traditional: Partially threaded screws and/or Kirschner wires
  • Alternative: Headless compression screws (associated with lower non-union rates and less hardware pain) 2
• Post-operative protocol:
  • Elevate extremity to reduce swelling
  • Apply ice following PRICE protocol (protection, rest, ice, compression, elevation)
  • Early mobilization to prevent stiffness
  • Progressive weight bearing as directed by surgeon

2. For Medial Ankle Sprains/Ligament Injuries

Grade I (Mild):

• PRICE protocol for 24-72 hours
• Early mobilization as tolerated
• Topical NSAIDs with or without menthol gel
• Specialized cushioning if needed

Grade II (Moderate):

• PRICE protocol for first 48-72 hours
• Oral NSAIDs or acetaminophen for pain control
• Supportive bracing or taping
• Progressive rehabilitation exercises
• Return to activity when pain-free with full range of motion

Grade III (Severe):

• Consider MRI to evaluate extent of ligament damage 1
• Immobilization with cast or boot for 1-3 weeks
• Progressive rehabilitation
• Possible referral to specialist if symptoms persist beyond 4-6 weeks

Rehabilitation Protocol

Early Phase (0-2 weeks):

• Control pain and swelling
• Gentle range of motion exercises
• Non-weight bearing or partial weight bearing as tolerated

Middle Phase (2-6 weeks):

• Progressive weight bearing
• Strengthening exercises
• Proprioception training
• Gait training

Late Phase (6+ weeks):

• Sport-specific exercises
• Return to activity when:
  • Full pain-free range of motion
  • Normal strength
  • Normal proprioception
  • Ability to perform sport-specific movements

Monitoring for Complications

• Non-union (up to 20% with traditional fixation techniques) 2
• Post-traumatic arthritis
• Chronic pain or instability
• Hardware-related discomfort
• Infection

Special Considerations

• For stress fractures of the medial malleolus (rare but seen in runners):

  • If visible on radiographs: Consider surgical fixation for athletes desiring early return to activity
  • If only visible on bone scan: Consider non-surgical management with immobilization 3

• For vascular injuries (rare but serious):

  • Monitor for strong signs: absent pulse, expanding hematoma, pulsatile bleeding
  • If suspected, perform CT angiography 1
  • Calculate Ankle-Brachial Index (ABI) - if <0.9, vascular injury is likely 1