Posterior Splint for Distal Fibular Fracture
For acute distal fibular fractures, a posterior splint (also called a sugar-tong or U-splint) is the recommended initial immobilization method, as it provides adequate stabilization while allowing for swelling and can be easily applied in the emergency setting.
Initial Immobilization Approach
The choice of splint depends on fracture stability and associated injuries:
Isolated, minimally displaced distal fibular fractures can be managed with a posterior splint that extends from below the knee to the toes, maintaining the ankle in neutral position 1
Stable ankle fractures (medial clear space <4mm on weight-bearing radiographs when possible) indicate the fracture can be managed conservatively with splinting 1
The posterior splint should be applied with the ankle at 90 degrees to prevent equinus contracture and allow for anticipated swelling in the first 48-72 hours 1
When to Consider Alternative Immobilization
Several factors indicate increased instability requiring closer follow-up or surgical consideration:
Medial tenderness, bruising, or swelling suggests deltoid ligament injury and potential instability 1
Fibular fracture above the syndesmosis (proximal to the ankle joint) indicates higher risk of syndesmotic injury 1
Bi- or trimalleolar fractures are inherently unstable and typically require surgical fixation rather than splinting alone 1
Open fractures or high-energy mechanisms warrant immediate orthopedic consultation 1
Duration and Follow-up
Initial splinting should be maintained for approximately 3 weeks with radiographic follow-up to confirm adequate healing 2, 3
Weight-bearing radiographs at follow-up provide critical information about fracture stability, particularly assessing the medial clear space 1
Transition to a removable walking boot or continued immobilization depends on radiographic healing and clinical stability 2, 3
Active Motion During Immobilization
Immediate active toe motion exercises should be initiated to prevent stiffness, which is one of the most functionally disabling complications 2, 3
Finger and toe motion does not adversely affect adequately stabilized fractures 2
Common Pitfalls to Avoid
Avoid circumferential casting initially in acute fractures due to risk of compartment syndrome from swelling 4
Do not miss associated injuries: Always examine for medial ankle tenderness (deltoid ligament), syndesmotic injury, and obtain knee radiographs if there is proximal fibular tenderness (Maisonneuve fracture pattern) 1
Monitor for complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 2, 3