What is the treatment plan for a lateral malleolus fracture?

Treatment Plan for Lateral Malleolus Fracture

For lateral malleolus fractures, open reduction and internal fixation (ORIF) with plate and screws is the standard of care, though intramedullary fixation is a viable alternative for specific cases, particularly those with soft tissue concerns. 1

Initial Evaluation

• Imaging:

  • Begin with standing (weight-bearing) radiographs including anteroposterior, medial oblique, and lateral projections 2
  • If radiographs are negative but clinical suspicion remains high, MRI is the preferred second-line study 3
  • CT may be useful for complex injuries such as posterior malleolar fracture and posterior pilon variant fractures 3

• Physical Examination:

  • Assess for point tenderness over the malleoli
  • Evaluate ability to bear weight
  • Check for associated injuries to medial malleolus or syndesmosis

Treatment Algorithm

1. Non-Displaced Fractures

• Protected weight-bearing with removable walking boot or cast for 4-6 weeks 2
• Avoid barefoot walking and flat shoes
• Regular follow-up at 2 weeks and 4-6 weeks to ensure maintained alignment 2

2. Displaced/Unstable Fractures

• Surgical fixation options:
  • Primary option: ORIF with plate and screws (current gold standard) 1
  • Alternative option: Intramedullary fixation (fibular nailing or IM screw) 1, 4
    • Consider for patients with soft tissue concerns due to minimal invasive approach 4
    • Allows earlier weight bearing, potentially accelerating rehabilitation 5

3. Complex Fractures

• For fractures with posterior malleolus involvement, consider modified posterolateral approach 6
• For compound loss of lateral malleolus and lateral ankle ligaments, reconstruction may require specialized techniques such as tendon-bone allograft 7

Post-Treatment Protocol

Traditional Protocol

• Immobilization: 4 weeks
• Progressive weight bearing
• Return to activity: 18-19 weeks 2

Accelerated Protocol

• Early mobilization
• Early weight bearing
• Return to activity: 13-14 weeks 2

Pain Management

• NSAIDs for pain control (first-line)
• Topical NSAIDs with or without menthol gel
• Acetaminophen as second-line treatment
• Avoid opioids due to potential risks 2

Rehabilitation

• Early gentle movement as tolerated to prevent stiffness
• Calf-muscle stretching
• Gradual increase in activity intensity and duration
• Use of heel cushions and arch supports during recovery 2

Monitoring and Follow-up

• Clinical and radiographic follow-up at 2 weeks and 4-6 weeks
• Monitor for complications:
  • Delayed union or non-union
  • Post-traumatic arthritis
  • Persistent pain or instability
  • Approximately 20% of patients may experience chronic pain 2

Pitfalls and Caveats

• Be aware that about one-fifth of patients with intramedullary fixation may require secondary procedures, mainly hardware removal 4
• Prolonged immobilization can lead to stiffness and delayed recovery
• Inadequate fixation may result in malunion, non-union, or post-traumatic arthritis
• Patients with comorbidities like diabetes require closer monitoring for complications