What is the treatment for a medial malleolar fracture?

Treatment of Medial Malleolar Fractures

The treatment of medial malleolar fractures should be determined by the degree of displacement, with non-displaced fractures (<2mm) managed non-operatively and displaced fractures (>2mm) requiring surgical fixation to prevent long-term complications such as nonunion and post-traumatic arthritis. 1

Initial Assessment

• Diagnosis requires standard radiographic views: anteroposterior, lateral, and mortise views 1
• Weight-bearing radiographs (if possible) provide crucial information about fracture stability
• Stability assessment: medial clear space <4mm confirms stability 1

Treatment Algorithm

Non-Operative Management

• Indicated for:

  • Non-displaced fractures (<2mm displacement)
  • Stable fractures (medial clear space <4mm)
  • Elderly or low-demand patients with minimal symptoms
  • Patients with high surgical risk

• Treatment protocol:

  • Immobilization with cast or boot for 4-6 weeks
  • Pain management with appropriate analgesics
  • Regular radiographic follow-up (every 2 weeks initially)
  • Progressive weight-bearing as tolerated after initial immobilization

Surgical Management

• Indicated for:

  • Displaced fractures (>2mm)
  • Unstable fractures (medial clear space >4mm)
  • Bi- or trimalleolar fractures
  • Active patients with higher functional demands
  • Open fractures

• Surgical options:

  • Open Reduction and Internal Fixation (ORIF) is the standard approach
  • Single or double screw fixation (both equally effective) 2
  • Arthroscopy-assisted reduction may provide superior short-term outcomes 3

Special Considerations

Fracture Pattern Considerations

• Supracollicular fractures: Surgical fixation preferred (higher pain rates when not fixed) 4
• Anterior collicular fractures: Non-operative management may be appropriate (only 10% report pain with non-operative treatment) 4
• Intercollicular fractures: Similar outcomes with operative and non-operative management 4

Associated Injuries

• Assess for associated deltoid ligament disruption
• Evaluate for chondral lesions (present in 32.4% of cases in arthroscopic assessment) 3
• Check for tears of anterior inferior tibiofibular ligament (present in 44.1% of arthroscopically assessed cases) 3

Rehabilitation Protocol

• Early phase (0-4 weeks):

  • Protected motion
  • Pain control
  • Pendulum exercises if appropriate

• Intermediate phase (4-8 weeks):

  • Begin gentle passive range of motion exercises
  • Progress to active-assisted range of motion as tolerated

• Late phase (8+ weeks):

  • Advance to strengthening exercises after fracture healing
  • Return to full activity typically between 6-8 weeks after treatment initiation 5

Follow-up and Monitoring

• Clinical and radiographic follow-up at 2-week intervals initially
• Monitor for:
  • Pain levels
  • Range of motion progress
  • Fracture healing
  • Functional improvement
  • Potential complications (malunion, nonunion, post-traumatic arthritis)

Common Pitfalls and Caveats

• Failure to obtain weight-bearing radiographs may lead to underestimation of instability
• Inadequate fixation of displaced fractures increases risk of nonunion and arthritis
• Overlooking associated injuries (ligamentous tears, chondral lesions) can lead to suboptimal outcomes
• Unnecessary fixation of stable anterior collicular fractures may increase pain 4
• Outcomes between operative and non-operative treatment may not differ significantly in the long term, despite initial advantages of surgical treatment 6, 3