From the Guidelines
The treatment for a subacute medial malleolus avulsion fracture should prioritize simple immobilization when fracture fragments are small, nonarticular, or minimally displaced, as this approach is supported by the American College of Foot and Ankle Surgeons 1. When managing a subacute medial malleolus avulsion fracture, it's crucial to consider the size and displacement of the fracture fragments.
- For non-displaced or minimally displaced fractures, immobilization in a walking boot or cast for 4-6 weeks is often sufficient, allowing for proper healing while minimizing the risk of complications.
- The decision to proceed with surgical intervention should be based on the fracture's characteristics, with larger, displaced fractures (greater than 2mm) potentially requiring surgical fixation to restore ankle stability and prevent nonunion.
- Pain management is an essential component of treatment, with NSAIDs like ibuprofen or naproxen commonly used for 1-2 weeks to control pain and inflammation.
- Following immobilization, a progressive rehabilitation program focusing on range of motion exercises, strengthening, and proprioception training for 6-12 weeks can help restore ankle function and prevent long-term sequelae. The goal of treatment is to balance the need for fracture healing with the prevention of joint stiffness and muscle atrophy, ultimately aiming to preserve ankle stability and prevent future complications such as post-traumatic arthritis, as highlighted by the principles outlined in the diagnosis and treatment of heel pain 1.
From the Research
Treatment Options for Subacute Medial Malleolus Avulsion Fracture
- Conservative treatment is a viable option for isolated fractures of the medial malleolus, with high rates of union and good functional results 2.
- Operation is typically reserved for more complex cases, such as bi- or trimalleolar fractures, open fractures, or injuries that compromise the skin 2.
- For small avulsion type fractures of the medial malleolus, tension-band fixation is a recommended technique, although it may result in prominent symptomatic implants and require secondary surgery for implant removal 3.
- Bicortical screw fixation has been shown to be a statistically stiffer construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques 3.
Specific Treatment Approaches
- Arthroscopy-assisted closed reduction and percutaneous internal fixation is a minimally invasive technique that has been shown to be effective in treating medial malleolus fractures, with good functional outcomes and low complication rates 4.
- Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures has been shown to yield satisfactory results, although there is an increased risk of nonunion and uncertainty regarding the development of posttraumatic arthritis 5.
Considerations for Treatment
- The choice of treatment approach depends on the specific characteristics of the fracture, including the degree of displacement and the presence of any associated injuries 2, 3, 5.
- The goal of treatment is to achieve stable fixation and promote healing, while minimizing the risk of complications and promoting optimal functional outcomes 2, 3, 4, 5.