From the Guidelines
Treatment for malleolar fractures should be guided by the stability and displacement of the fracture, with stable, non-displaced fractures managed conservatively and unstable or displaced fractures requiring surgical fixation. The initial evaluation of acute trauma to the ankle should include radiographs, specifically three standard views: anteroposterior, lateral, and mortise views, as recommended by the American College of Radiology 1. Weight-bearing radiographs, if possible, provide important information on fracture stability, with a medial clear space of <4 mm confirming stability 1.
Key considerations in treatment include:
- Stable, non-displaced fractures can be managed with a short leg cast or walking boot for 6-8 weeks, along with non-weight bearing or partial weight bearing as directed by the physician.
- Unstable or displaced fractures require surgical fixation with plates and screws, followed by a period of immobilization and progressive rehabilitation.
- Pain management typically includes acetaminophen or NSAIDs like ibuprofen for 1-2 weeks.
- Post-treatment rehabilitation is crucial and includes range of motion exercises, strengthening, and gradual return to weight-bearing activities.
It is essential to note that complications can include malunion, nonunion, post-traumatic arthritis, and chronic ankle instability, emphasizing the importance of proper anatomic reduction to restore normal ankle biomechanics and prevent long-term disability 1. The classification of these fractures using the Weber or Lauge-Hansen systems helps guide treatment based on the level of fibular fracture relative to the ankle joint and the mechanism of injury.
From the Research
Treatment Options for Malleolar (Ankle) Fractures
The treatment options for malleolar (ankle) fractures can be categorized into nonoperative and operative treatments.
- Nonoperative treatment is often recommended for stable fractures, such as isolated lateral malleolar fractures, and can include reduction by manipulation and immobilization in a plaster cast for 7 or 8 weeks 2.
- Operative treatment is typically indicated for unstable fractures, such as Weber B pronation-abduction injuries, Weber C fractures, and trimalleolar ankle fractures with a posterior malleolar component 3, 4, 5.
- The choice of treatment depends on various factors, including the classification and interpretation of the fracture type, stability, and the presence of syndesmotic injury 3, 4.
- In some cases, minimally invasive fixation or no fixation at all may be considered, particularly when there are concerns about the soft tissue envelope, as seen in a case report of an open medial malleolar fracture 6.
Nonoperative Treatment
Nonoperative treatment may be suitable for:
- Isolated lateral malleolar fractures
- Stable Weber B supination-external rotation injuries
- Fractures with minimal displacement and no instability
Operative Treatment
Operative treatment is often necessary for:
- Unstable Weber B supination-external rotation injuries
- Weber B pronation-abduction injuries
- Weber C fractures
- Trimalleolar ankle fractures with a posterior malleolar component
- Fractures with significant displacement or instability
Considerations for Posterior Malleolar Fractures
When dealing with trimalleolar ankle fractures, the management of the posterior malleolar component is crucial, and may involve either direct fixation or indirect stabilization with trans-syndesmotic fixation 5.