Does a spiral fracture of the ankle require surgery?

Does a Spiral Fracture of the Ankle Require Surgery?

A spiral fracture of the ankle does not automatically require surgery—the critical determining factor is ankle joint stability, which is assessed by evaluating fracture displacement, medial clear space, and associated ligamentous or bony injuries. 1, 2

Stability Assessment: The Key Decision Point

The most important criterion for determining surgical versus non-surgical management is ankle stability 1:

• Medial clear space <4 mm confirms ankle stability and indicates conservative management is appropriate 1
• Displacement >2 mm, ankle mortise instability, bi- or tri-malleolar involvement, or high-energy injury mechanism mandate surgical intervention 1
• Spiral fractures of the lateral malleolus (Weber B) can be stable or unstable depending on the mechanism of injury 2

Non-Surgical Management Criteria

Conservative treatment is appropriate when:

• The ankle joint shape remains intact in both radiographic projections 2
• There is no significant deep deltoid ligament injury 2
• No additional fractures exist within the ankle region 2
• The fracture is nondisplaced or minimally displaced with maintained joint congruity 3, 1

For stable fractures, immediate full weight-bearing as tolerated with a removable boot or brace is recommended 1

Surgical Indications

Surgery is required when:

• Displacement exceeds 2 mm 1
• Ankle mortise instability is present 1
• Bi-malleolar or tri-malleolar fractures exist 1
• Deep deltoid ligament injury is confirmed 2
• High-energy injury mechanism suggests occult instability 1

Essential Diagnostic Workup

Imaging requirements:

• Standard three-view radiographs (anteroposterior, lateral, and mortise views) are mandatory 1
• Weight-bearing radiographs are preferred as they detect dynamic instabilities not visible on non-weight-bearing films 1
• CT scanning should be obtained for spiral-type fractures to identify occult ankle injuries, as 64.7% of spiral tibial shaft fractures have concomitant ankle injuries 4

Critical Pitfalls to Avoid

• Inadequate imaging may miss associated injuries—spiral fractures are frequently associated with posterior malleolar fractures, lateral malleolar fractures, and ligamentous injuries that require surgical fixation 3, 4
• Patients with diabetes, neuropathy, or osteoporosis require more cautious management with longer immobilization periods 1
• Follow-up radiographs are essential to detect late displacement that may occur after initial conservative management 1
• Suspected unstable ankle fractures should be referred to centers with surgical expertise 2

Post-Treatment Management

For both surgical and non-surgical cases:

• Appropriate pain management is crucial 3
• Antibiotic prophylaxis for open fractures or surgical cases 3
• Early mobilization with protected weight-bearing based on fracture stability 3
• Rehabilitation should include early physical training, muscle strengthening, and balance training 5, 3