What is the management of a nondisplaced distal fibula fracture?

Management of Nondisplaced Distal Fibula Fractures

Conservative management with immobilization is the recommended treatment for nondisplaced distal fibula fractures, with excellent healing outcomes in over 90% of cases. 1

Initial Assessment

• Obtain three standard radiographic views: anteroposterior, lateral, and mortise views to confirm the diagnosis and assess fracture stability 2
• Evaluate for fracture stability by checking:
  • Medial tenderness, bruising, or swelling
  • Location of fracture relative to the syndesmosis
  • Presence of other malleolar involvement
  • Whether it's an open or high-energy injury 2
• Consider weight-bearing radiographs to further assess stability (medial clear space <4 mm confirms stability) 2

Treatment Algorithm

For Stable Nondisplaced Distal Fibula Fractures:

1. Immobilization:

   • Short-term immobilization with a removable boot or cast for 4-6 weeks 1
   • Progressive weightbearing as tolerated based on pain levels

2. Follow-up Imaging:

   • Recent evidence suggests that routine radiographic follow-up may not be necessary for all patients
   • Consider radiographs only when clinically indicated (new trauma, pain score >6, loss of range of motion, or neurovascular symptoms) 3

3. Pain Management:

   • NSAIDs for pain and inflammation control 2
   • Consider vitamin C supplementation to prevent disproportionate pain 2

4. Rehabilitation:

   • Early finger motion exercises to prevent stiffness 2
   • Directed home exercise program including active motion exercises after immobilization period 2

When to Consider Surgical Management:

Surgery should be considered if any of the following are present:

• Displacement >3 mm
• Angulation >10 degrees
• Evidence of syndesmotic injury
• Medial clear space >4 mm on weight-bearing radiographs
• Persistent pain and instability after conservative management 2, 1

Special Considerations for Elderly Patients

While traditionally ankle fractures in the elderly were managed nonoperatively, recent evidence suggests a shift toward operative management even in this population:

• Nonoperative management of nondisplaced fractures remains appropriate for most elderly patients 1
• For displaced fractures in elderly patients with multiple comorbidities, minimally invasive intramedullary nailing may be considered as an alternative to traditional ORIF 4
• Consider orthogeriatric co-management to improve functional outcomes and reduce mortality 2

Expected Outcomes and Timeframes

• Most nondisplaced fibular fractures heal successfully with nonoperative measures 5
• Average healing time: approximately 7 weeks 5
• Return to normal activities: approximately 9 weeks 5

Potential Complications

• Nonunion (rare but possible): Patients with persistent localized pain, tenderness at the fracture site, and antalgic gait beyond 3 months should be evaluated for potential nonunion 6
• Joint stiffness and chronic pain can develop if rehabilitation is inadequate 2
• Post-traumatic arthritis may develop in cases with unrecognized instability 2

Monitoring for Complications

• Persistent lateral ankle pain beyond expected healing time warrants further evaluation
• If symptoms persist despite appropriate conservative management, consider advanced imaging and possible surgical intervention 6

Remember that while most nondisplaced distal fibula fractures heal well with conservative management, careful assessment of stability is crucial to determine the appropriate treatment approach. Weight-bearing radiographs are particularly valuable in confirming stability and guiding treatment decisions.