From the Guidelines
Surgical fixation is the recommended management for medial malleolus fractures, especially if displacement exceeds 2mm or if the ankle mortise is unstable, as it is considered a high-risk fracture with a tendency for nonunion or delayed union 1. The management of medial malleolus fractures is crucial for maintaining ankle joint congruity and stability. According to the latest evidence, certain stress fractures, including those of the medial malleolus, are considered high-risk due to their tendency for nonunion or delayed union 1.
Key Considerations
- High-risk stress fractures, such as those of the medial malleolus, require prompt identification and management to prevent progression to more serious fractures and complications 1.
- Surgical intervention is necessary for maintaining ankle joint congruity and stability, as the medial malleolus is essential for proper ankle biomechanics and preventing long-term arthritis.
- Post-operative care typically involves immobilization, followed by progressive weight bearing and range of motion exercises, with physical therapy to restore strength and mobility.
Treatment Options
- For non-displaced fractures (less than 2mm displacement), conservative management with a non-weight bearing cast for 6-8 weeks may be appropriate.
- However, most medial malleolus fractures require surgical fixation, especially if displacement exceeds 2mm or if the ankle mortise is unstable.
- Surgery typically involves open reduction and internal fixation (ORIF) using two parallel cancellous screws (4.0mm) or tension band wiring.
- For comminuted fractures, a buttress plate may be necessary.
Complications and Pain Management
- Complications to monitor include nonunion (especially in diabetic patients), malunion, hardware irritation, and post-traumatic arthritis.
- Pain management typically includes NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily), with short-term opioids like hydrocodone/acetaminophen 5/325mg every 4-6 hours as needed for severe pain in the immediate post-operative period.
From the Research
Management of Medial Malleolus Fractures
The management of medial malleolus fractures can be achieved through various techniques, including:
- Operative management using partially threaded screws and/or Kirschner wire fixation 2
- Alternative fixation techniques such as headless compression screws, which have been shown to provide effective compression and good clinical outcomes 2, 3
- Antegrade screw fixation, which is an alternative strategy for fixing medial malleolus fractures 4
Treatment Outcomes
The treatment outcomes of medial malleolus fractures can vary depending on the technique used. Studies have reported:
- A non-union rate of as high as 20% with conventional techniques 2
- Good clinical outcomes and a low rate of complications with headless compression screws 2, 3
- Successful healing and return to play with both nonoperative and operative interventions for medial malleolar stress fractures 5
Biomechanical Evaluation
Biomechanical studies have evaluated the stability of different fixation methods for medial malleolus fractures, including:
- A comparison of partially threaded cancellous screws and headless compression screws, which found no statistically significant difference between the two methods 3
- An evaluation of the axial rotational force required to create fracture line displacement, which found that headless compression screws are a viable alternative to partially threaded cancellous screws 3
Clinical Trials
Clinical trials have been conducted to compare the outcomes of operative and non-operative management of medial malleolus fractures, including:
- A prospective randomised controlled trial to determine if any difference exists in patient reported and surgical outcomes between operative and non-operative treatment of medial malleolar fractures 6