What is the recommended treatment for a distal non-displaced fibula fracture?

Management of Distal Non-Displaced Fibula Fractures

Conservative management with immobilization is the recommended treatment for distal non-displaced fibula fractures, as this approach yields excellent outcomes in more than 90% of cases. 1, 2

Assessment of Fracture Stability

Before deciding on treatment, it's crucial to determine fracture stability:

• Radiographic evaluation:

  • Standard radiographs (3 views: posteroanterior, lateral, and oblique) for initial diagnosis 3
  • Upright weight-bearing radiographs are superior for demonstrating true displacement compared to supine views 3
  • Stress radiographs may be necessary to detect associated mortise instability 2

• Stability criteria - a fracture is considered stable when:

  • Minimal displacement (less than 3mm interfragmentary gap)
  • Minimal angulation (less than 10 degrees)
  • No disruption of the ankle mortise 3, 1

Treatment Protocol

For Stable Non-Displaced Fractures:

1. Immobilization:

   • Use a simple removable ankle brace or walking boot rather than a cast 3
   • Duration: 4-6 weeks depending on clinical and radiographic healing

2. Weight-bearing status:

   • Protected weight-bearing with walking aids initially
   • Progress to full weight-bearing as tolerated based on pain and radiographic evidence of healing

3. Pain management:

   • NSAIDs for pain and inflammation control 3
   • Consider acetaminophen if NSAIDs are contraindicated

For Unstable or Displaced Fractures:

Surgical intervention is indicated when:

• Displacement >3mm
• Angulation >10 degrees
• Evidence of ankle mortise instability
• Fractures at the same level as tibial fractures when tibial fixation is performed 4

Rehabilitation Protocol

1. Early mobilization:

   • Begin active range of motion exercises after initial pain subsides
   • Directed home exercise program to prevent stiffness 3

2. Progressive rehabilitation:

   • Gradually increase weight-bearing as healing progresses
   • Strengthening exercises after adequate healing (typically 6-8 weeks)

3. Return to activities:

   • Gradual return to normal activities at 8-12 weeks based on radiographic healing and clinical symptoms

Monitoring and Follow-up

• Follow-up radiographs at 2,6, and 12 weeks to assess healing
• Monitor for complications such as:
  • Joint stiffness
  • Chronic pain
  • Post-traumatic arthritis 3

Important Considerations

• Diabetic patients require close monitoring of skin to prevent pressure points and breakdown 3
• Smoking cessation is strongly advised as it increases nonunion rates 3
• Elderly patients should be evaluated for osteoporosis risk factors and consider calcium and vitamin D supplementation 3

Common Pitfalls to Avoid

1. Failing to obtain weight-bearing radiographs - supine views may underestimate displacement
2. Overlooking ankle mortise instability - stress views may be necessary
3. Prolonged immobilization - can lead to joint stiffness and muscle atrophy
4. Delayed treatment of persistent symptoms - warrant prompt advanced imaging rather than prolonged observation 3

The evidence strongly supports conservative management for truly stable non-displaced distal fibula fractures, with surgical intervention reserved for unstable patterns or those with ankle mortise disruption 1, 2.