What is the recommended treatment for a distal fibula fracture in a 76-year-old female?

Management of Distal Fibula Fracture in a 76-Year-Old Female

Operative management is recommended for distal fibula fractures in elderly patients with osteoporosis, as non-operative management has poor outcomes in this population. 1

Assessment and Diagnosis

• Obtain upright radiographs (posteroanterior, lateral, and oblique views) to accurately assess fracture displacement 2
• Consider CT without contrast if radiographs are equivocal but clinical suspicion remains high 2
• Evaluate for associated soft tissue injuries and syndesmotic instability

Treatment Approach

Surgical Considerations

• Surgical fixation is preferred over conservative management in elderly patients with osteoporotic distal fibula fractures 1
• Surgical options include:
  1. Locked plate systems (preferred for osteoporotic bone)
  2. Anti-glide plate construct
  3. Dual plating constructs for additional stability
  4. Intramedullary fibular nail (beneficial for poor soft tissue conditions)
  5. Plate with tibial pro-fibular screws
  6. Injectable bone cement augmentation

Specific Technique Recommendations

• Anatomically contoured locking plates provide strong and stable fixation 3
• Consider minimally invasive intramedullary nailing in cases of poor bone quality and/or critical soft tissue conditions 4
• Double plating may be considered for problematic fractures requiring enhanced fixation 5

Postoperative Management

• Orthogeriatric co-management improves functional outcomes and reduces mortality 2
• Consider early mobilization and weight-bearing:
  • With anatomically contoured locking plates, immediate full weight-bearing may be possible 3
  • With standard fixation, partial weight-bearing (15-20 kg) in an ankle foot orthosis or cast for 6 weeks 4
• Implement a directed home exercise program including active motion exercises to prevent stiffness 2

Important Considerations for Elderly Patients

• Evaluate for osteoporosis risk factors and consider calcium and vitamin D supplementation 2
• Monitor diabetic patients closely for skin pressure points and breakdown 2
• Advise smoking cessation as it increases nonunion rates and leads to inferior clinical outcomes 2
• Ensure appropriate pain management and early mobilization to prevent complications 6

Potential Complications

• Implant failure due to poor bone quality
• Wound healing complications (lower with intramedullary nailing compared to lateral plating) 4
• Joint stiffness, chronic pain, and post-traumatic arthritis 2
• Nonunion (though rare with modern fixation techniques - reported union rates with intramedullary nailing range from 97.4-100%) 4

Follow-up Care

• Regular assessment of wound healing and radiographic union
• Monitor for hardware-related pain or complications
• Ensure compliance with rehabilitation protocols
• Consider secondary fracture prevention strategies as recommended for fragility fractures 6