What is the management for a suspected non-united lateral malleolus tip fracture found on tibia and fibula X-rays (X-radiographs)?

Management of Suspected Non-united Lateral Malleolus Tip Fracture

For a suspected non-united lateral malleolus tip fracture found on tibia and fibula X-rays, surgical management with debridement and internal fixation using autologous bone graft is recommended for symptomatic cases, while asymptomatic cases may be managed conservatively.

Diagnostic Approach

Initial Assessment

• Use the Ottawa Ankle Rules (OAR) to confirm fracture suspicion 1
  • Pain on the dorsal side of one or both malleoli
  • Palpation pain at the basis of the metatarsal bone V
  • Palpation pain of the navicular bone
  • Inability to walk at least four steps

Imaging

• Standing (weight-bearing) radiographs including anteroposterior, medial oblique, and lateral views are preferred to detect dynamic abnormalities 2
• If radiographs are inconclusive but clinical suspicion remains high:
  • Consider MRI to confirm non-union and assess soft tissue status
  • CT scan may be helpful for complex injuries or preoperative planning 2

Treatment Algorithm

For Symptomatic Non-union

1. Surgical Management:
   • Open reduction and internal fixation with autologous bone grafting 3
   • Surgical approach:
     • Longitudinal incision over the affected area
     • Careful dissection down to the periosteum
     • Identification and protection of surrounding nerves
     • Debridement of the non-union site
     • Stable fixation with appropriate hardware 2

For Asymptomatic or Minimally Symptomatic Non-union

1. Conservative Management:
   • Activity modification
   • Pain management with multimodal approach:
     • Acetaminophen and NSAIDs as first-line treatment 2
     • Topical NSAIDs with or without menthol gel 2
     • Avoid opioids due to potential risks 2
   • Regular monitoring for progression of symptoms

Rehabilitation Protocol

Post-Surgical Rehabilitation

• Early mobilization to prevent stiffness and promote healing 2
• Progressive weight-bearing based on stability of fixation
• Follow-up at 2 weeks and 4-6 weeks to ensure maintained alignment and assess healing 2
• Monitor for complications:
  • Delayed union or persistent non-union
  • Post-traumatic arthritis
  • Persistent pain or instability
  • Reflex sympathetic dystrophy (as noted in long-term follow-up) 3

Timeline for Return to Activity

• Traditional protocol: Return to full activity in 18-19 weeks 2
• Accelerated protocol: Return to full activity in 13-14 weeks with early mobilization 2

Special Considerations

Risk Factors for Non-union

• Male gender
• Supination fractures
• Weber type C fractures
• Primary internal fixation complications 3

Prevention of Future Complications

• Gradual increase in activity intensity and duration
• Appropriate footwear
• Cross-training to reduce repetitive stress
• Address biomechanical abnormalities with orthoses 2
• Regular muscle stretching and weight loss if indicated 2

Monitoring and Follow-up

• Clinical and radiographic follow-up at regular intervals
• Any increase in pain during rehabilitation suggests overloading and requires temporary reduction in activity 2
• Consider alternative fixation methods such as intramedullary fixation for specific fracture patterns if revision surgery is needed 4