What is the recommended weight-bearing status for a patient with a nondisplaced, mildly comminuted fracture of the distal fibula metaphysis?

Weight-bearing Status for Nondisplaced, Mildly Comminuted Distal Fibula Metaphysis Fracture

Immediate, full weight-bearing as tolerated is recommended for patients with a nondisplaced, mildly comminuted fracture of the distal fibula metaphysis. 1

Rationale for Weight-bearing Status

• Weight-bearing radiographs are preferred for fracture assessment as they can detect dynamic abnormalities such as joint mal-alignment, joint subluxation, and fracture displacement that may not be apparent on non-weight-bearing radiographs 1
• The American Academy of Orthopaedic Surgeons (AAOS) provides a limited strength option recommendation supporting immediate, full weight-bearing to tolerance after surgical fixation of fractures 1
• This recommendation can be extended to stable, nondisplaced fractures of the distal fibula metaphysis that do not require surgical intervention 2
• Medial clear space of <4 mm confirms ankle stability, which is the most important criterion in determining weight-bearing status for malleolar fractures 1

Assessment of Fracture Stability

• Standard radiographic protocols should include three views: anteroposterior, lateral, and mortise views to properly assess fracture stability 1, 2
• Factors that would indicate instability and potentially alter weight-bearing status include:
  • Medial tenderness, bruising, or swelling 1
  • Fibular fracture above the syndesmosis 1
  • Bi- or trimalleolar fractures 1
  • Open fracture 1
  • High-energy fracture injury 1
• For nondisplaced, mildly comminuted fractures of the distal fibula metaphysis without these factors, the fracture is considered stable 2

Clinical Implementation

• Protection with a removable boot or brace is typically recommended while allowing weight-bearing as tolerated 1
• Assistive devices such as crutches may be used initially for comfort but are not mandatory if the patient can tolerate full weight-bearing 1
• Patients should be advised to return for care and re-evaluation if discomfort worsens or does not improve 1
• Weight-bearing should be initiated early to:
  • Promote fracture healing through controlled micromotion 3
  • Prevent muscle atrophy and joint stiffness 1
  • Maintain functional independence 1

Special Considerations

• In cases of diabetic patients with neuropathy, more caution may be needed, and a non-removable knee-high device with partial weight-bearing might be preferred 1
• For stress fractures of the fibula, non-weight-bearing precautions are typically recommended initially, with return to activity in approximately 9 weeks 3
• Patients with poor bone quality or osteoporosis may require additional protection, but weight-bearing is still generally encouraged 1

Follow-up Recommendations

• Clinical and radiographic follow-up should be scheduled at 2-3 weeks to ensure proper healing and maintenance of alignment 2
• If there is any evidence of displacement or instability on follow-up imaging, the weight-bearing status should be reassessed 1
• Full healing of distal tibial metaphyseal fractures (which often accompany fibular fractures) can be expected regardless of fracture type, age, and gender 4