What is the treatment for a closed fibula fracture?

Treatment of Closed Fibula Fractures

For closed fibula fractures, non-operative treatment with rigid immobilization is recommended for stable fractures, while surgical fixation is indicated for fractures with significant displacement or instability.

Assessment of Fracture Stability

• Radiographic parameters indicating instability and need for surgical intervention include:

  • Radial shortening >3 mm
  • Dorsal tilt >10°
  • Intra-articular displacement 1
  • Medial clear space >6 mm (indicating syndesmotic instability) 2

• Fracture patterns at the distal tibiofibular syndesmosis can be classified as:

  • Supination-external rotation (SE): fracture extends from anterior edge in posterosuperior direction
  • Pronation-abduction (PA): fracture extends from medial surface transversely or obliquely in laterosuperior direction 3

Treatment Algorithm

Non-operative Management

• Indicated for:

  • Stable isolated fibula fractures with medial clear space ≤6 mm 2
  • Non-displaced fractures 1

• Treatment protocol:

  • Rigid immobilization (cast or boot) rather than removable splints 1
  • Weight-bearing status depends on fracture location and stability
  • Duration typically 6-8 weeks until radiographic healing 4

• Expected outcomes:

  • High union rates (>99%) 2
  • Return to baseline activities by approximately 9 weeks 4
  • Long-term functional outcomes comparable to surgical treatment (mean follow-up of 5.3 years) 2

Surgical Management

• Indicated for:

  • Unstable fractures with displacement
  • Fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 1
  • Syndesmotic injury 1

• Surgical techniques:

  • Plate osteosynthesis (most common method)
    • Tubular plates (94.1% of cases)
    • Locking plates (5.9% of cases) 5
  • Fixation of associated syndesmotic injuries when present 1

• Expected outcomes:

  • High union rate of 99.5% with plate fixation 5
  • Overall complication rate of 19.3%, with majority (79.5%) being minor complications 5
  • Hardware removal may be required in approximately 13.4% of cases due to symptomatic hardware 5

Special Considerations

• Stress fractures of the fibula:

  • Relatively common in athletes and military recruits (up to 8.6% of all stress fractures)
  • Non-operative management with activity modification is highly effective
  • Healing typically occurs by 7 weeks
  • Return to activity by 9 weeks on average 4

• Surgical site infection prevention:

  • Antibiotic prophylaxis with systemic cefazolin or clindamycin is recommended for surgical cases 1
  • Local antibiotic strategies (vancomycin powder, tobramycin-impregnated beads) may be beneficial 1
  • Negative pressure wound therapy may mitigate risk of revision surgery or surgical site infections after closed fracture fixation 1

Potential Complications

• Non-operative treatment:

  • Deep venous thrombosis (rare) 2
  • Delayed union or malunion (uncommon with appropriate patient selection) 2

• Surgical treatment:

  • Hardware-related symptoms requiring removal (13.4%) 5
  • Wound infection requiring antibiotics (3%) 2
  • Major complications including deep infection, nonunion/malunion, and osteomyelitis (1.7% requiring subsequent surgery) 5

Follow-up Recommendations

• Regular radiographic assessment to ensure proper alignment and healing
• Gradual return to weight-bearing as fracture healing progresses
• Physical therapy for range of motion and strengthening exercises after immobilization period
• Hardware removal may be considered for symptomatic patients after fracture healing 5