What is the recommended treatment for a nondisplaced fracture of the distal fibula below the syndesmosis?

Treatment of Nondisplaced Fracture of Distal Fibula Below Syndesmosis

Nondisplaced distal fibular fractures below the syndesmosis should be treated with conservative management using a removable splint for approximately 3 weeks, followed by gradual return to activity. 1

Initial Management

• Conservative treatment is the standard of care for nondisplaced distal fibular fractures below the syndesmosis, as these fractures typically heal well with minimal intervention 1, 2
• Removable splints are recommended by the American Academy of Orthopaedic Surgeons (AAOS) as an appropriate option for treating minimally displaced distal fibular fractures 1
• Immobilization should be maintained for approximately 3 weeks, with radiographic follow-up at that time to confirm adequate healing 1

Rehabilitation Protocol

• Active finger motion exercises should be performed following diagnosis to prevent stiffness, which is one of the most functionally disabling adverse effects of distal radius/fibula fractures 1
• Finger motion does not adversely affect adequately stabilized fractures in terms of reduction or healing 1
• After immobilization is discontinued, gradual return to weight-bearing and activity should be implemented 1, 2

When to Consider Surgical Management

• Surgical intervention is indicated if there is:
  • Postreduction radial shortening >3 mm 3
  • Dorsal tilt >10° 3
  • Intra-articular displacement 3
  • Development of symptomatic nonunion despite appropriate conservative management 2

Monitoring and Follow-up

• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal to confirm adequate healing 1
• Monitor for potential complications such as:
  • Skin irritation or muscle atrophy, which occur in approximately 14.7% of immobilization cases 1
  • Signs of nonunion, which may present as persistent localized pain, reproducible tenderness at the fracture site, and antalgic gait pattern 2

Special Considerations

• If the fracture is associated with syndesmosis injury, treatment approach differs:
  • Grade 1 syndesmosis injuries can be managed conservatively with 1-3 weeks of immobilization 4
  • Grade 2 and 3 syndesmosis injuries typically require surgical intervention 4
• Be aware that distal fibula nonunion, while uncommon in properly treated nondisplaced fractures, can be a cause of persistent lateral ankle symptoms 2
• If nonunion develops despite appropriate conservative treatment, surgical stabilization with autologous bone grafting and plate/screw fixation has shown good results in resolving symptoms 2

Pitfalls to Avoid

• Removing immobilization too early before adequate healing can lead to displacement or nonunion 1, 2
• Failure to recognize and address persistent pain at the fracture site after conservative treatment may indicate development of nonunion 2
• Overlooking associated injuries, particularly to the syndesmosis, can lead to poor outcomes 4, 5
• Early weight-bearing before adequate healing may result in loss of reduction 6