What are the treatment options for an oblique minimally displaced fracture of the distal fibula and medial malleolar fracture in a 68-year-old female?

Treatment of Oblique Minimally Displaced Distal Fibula and Medial Malleolar Fracture in a 68-Year-Old Female

This bimalleolar ankle fracture in a 68-year-old female requires surgical fixation with open reduction and internal fixation (ORIF) of both the medial malleolus and distal fibula, as the presence of a medial malleolar fracture indicates deltoid ligament complex disruption and ankle instability that will not heal adequately with conservative management alone.

Rationale for Surgical Management

Why Surgery is Indicated

• Bimalleolar fractures are inherently unstable due to disruption of both the lateral (fibula) and medial (deltoid ligament complex/medial malleolus) ankle stabilizers, requiring anatomic restoration to prevent chronic instability, post-traumatic arthritis, and functional disability 1

• The medial malleolar component is particularly critical because medial malleolar fractures have historically shown nonunion rates as high as 20% with inadequate fixation, and any residual displacement leads to altered joint mechanics and accelerated arthritis 2

• Even minimally displaced bimalleolar fractures require surgical stabilization because the fracture pattern indicates a complete disruption of ankle mortise stability 1, 3

Age Considerations

• While the patient is 68 years old and within the elderly population where conservative management of isolated distal radius fractures may be acceptable 4, ankle fractures behave differently than wrist fractures and require weight-bearing stability that cannot be achieved with casting alone in bimalleolar patterns 1

• Elderly patients who undergo appropriate surgical fixation of ankle fractures achieve reliable healing and functional outcomes comparable to younger patients when proper technique is used 1

Surgical Technique Recommendations

Medial Malleolus Fixation

• Use headless compression screws for medial malleolar fixation rather than traditional partially threaded screws, as this technique achieves:
  • Only 2% nonunion rate (compared to historical 20% with conventional screws) 2
  • Minimal need for hardware removal (2% vs. higher rates with prominent screw heads) 2
  • Reduced postoperative pain over hardware sites (only 23% mild discomfort vs. frequent complaints with traditional screws) 2

Distal Fibula Fixation

• Perform open reduction with plate and screw fixation of the distal fibula to restore:

  • Anatomic length and rotation of the fibula 1
  • Proper ankle mortise width and talar positioning 3
  • Lateral ankle stability 1

• Plate fixation is preferred over isolated screw fixation for oblique fibular fractures to provide rotational control and compression across the fracture site 1

Adjunctive Measures

• Consider bone grafting if there is any comminution or bone void, particularly given the patient's age and potential for osteoporosis, as grafting was used in the majority of successful nonunion repairs 1

• Evaluate for occult avulsion fractures off the distal tibia during surgery, as these are present in 39% of cases and may require additional fixation 3

Postoperative Management Protocol

Immobilization and Weight-Bearing

• Initial period of non-weight-bearing with splint immobilization for 2 weeks until suture removal 1

• Progressive weight-bearing as tolerated after radiographic confirmation of early healing at 3 weeks 5

• Expect average healing time of 5.2 months for complete bony consolidation 1

Rehabilitation

• Initiate active finger and toe motion exercises immediately after surgery to prevent stiffness, which is one of the most functionally disabling complications 5, 6

• Begin ankle range of motion exercises once fracture stability is confirmed, typically after 3-6 weeks 5

• Early mobilization does not adversely affect adequately stabilized fractures 5

Follow-Up Schedule

• Radiographic evaluation at 2 weeks (suture removal), 3 weeks, 6 weeks, 3 months, and 6 months to confirm progressive healing 5, 1

• Functional assessment at 6 months and 12 months using validated outcome measures 1

Common Pitfalls to Avoid

• Do not attempt conservative management with casting alone for bimalleolar fractures, even if minimally displaced, as this leads to unacceptable rates of malunion, chronic instability, and post-traumatic arthritis 1

• Avoid using traditional partially threaded screws for medial malleolar fixation due to high rates of prominent hardware complaints and potential nonunion 2

• Do not delay surgery beyond 2 weeks if possible, as delayed treatment increases the risk of nonunion and requires more extensive reconstruction with bone grafting 1

• Monitor for immobilization-related complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of cases 5, 6

Expected Outcomes

• With appropriate surgical fixation, expect reliable bony healing in >95% of cases with modern techniques 2, 1

• Functional outcomes and range of motion should be similar to patients who undergo acute operative treatment of ankle fractures 1

• Mean follow-up studies show resolution of all fractures with proper surgical technique at an average of 33.9 months 1