What are the next steps for a patient 4 months after a non-operative right distal fibula fracture?

Management of Non-Operative Distal Fibula Fracture at 4 Months Post-Injury

At 4 months post-injury from a non-operatively treated distal fibula fracture, the patient should be assessed for clinical and radiographic union, persistent pain, functional limitations, and ankle stability—if the fracture has healed and function is acceptable, transition to full activity; if symptomatic non-union or persistent dysfunction exists, consider surgical intervention with open reduction and internal fixation.

Initial Assessment at 4 Months

Clinical Evaluation

• Assess for fracture union by evaluating tenderness at the fracture site, ability to bear weight without pain, and absence of motion at the fracture site 1
• Evaluate functional status including range of motion, weight-bearing tolerance, and return to activities of daily living 1
• Document pain levels using standardized measures, as persistent pain may indicate non-union or other complications 1

Radiographic Assessment

• Obtain current radiographs to assess fracture healing, though evidence shows no difference in outcomes based on frequency of radiographic evaluation for distal radius fractures (similar principles apply to fibula fractures) 2
• Look for signs of union including bridging callus and trabecular continuity across the fracture site 3
• Identify atrophic non-union patterns characterized by lack of callus formation and persistent fracture gap, particularly in transverse fracture patterns 3

Management Based on Clinical Findings

If Fracture Has United (Expected in Most Cases)

Progressive rehabilitation should be the primary focus:

• Advance weight-bearing to full weight-bearing as tolerated if not already achieved 4, 1
• Implement active range of motion exercises to restore ankle mobility 2
• Consider home exercise program as evidence shows this is equally effective as supervised therapy for uncomplicated healing 2
• Return to full activities can typically occur once clinical union is achieved and functional goals are met 1

If Symptomatic Non-Union is Present (Rare but Important)

Surgical intervention is indicated for symptomatic atrophic non-union:

• Open reduction and internal fixation (ORIF) with plate fixation is the treatment of choice 3
• Consider bone grafting in cases of atrophic non-union where bone stock is deficient 3
• Use anatomically contoured locking plates which provide stable fixation and allow immediate weight-bearing postoperatively 4
• Expect successful union as all cases in reported series achieved union and symptom resolution with surgical treatment 3

Common Pitfalls and Caveats

Atrophic Non-Union Recognition

• Transverse Weber A fractures (distal to the ankle joint line) can rarely develop atrophic non-union despite being considered stable injuries 3
• Persistent pain beyond 3-4 months should prompt investigation for non-union rather than assuming normal healing trajectory 3
• Blood supply variations to the distal fibula may predispose certain fracture patterns to non-union 3

Therapy Considerations

• Supervised therapy is not routinely necessary as evidence is inconsistent for its benefit over home exercise programs in uncomplicated cases 2
• Specific patient subsets may benefit from supervised therapy if complications like stiffness or complex regional pain syndrome develop 2
• Active finger motion exercises should have been initiated early to prevent stiffness (applicable principle from distal radius literature) 2

Expected Outcomes

Non-Operative Treatment Success

• Union rate approaches 100% for stable isolated distal fibula fractures treated non-operatively 1
• Long-term functional outcomes at mean 5.3 years follow-up show excellent results with mean Olerud-Molander scores of 84 and AOFAS scores of 93 1
• Quality of life returns to normal with EQ-5D scores of 0.8-0.9 1

Surgical Treatment if Required

• Union rate of 99.5% with plate fixation when surgery is performed 5
• Complication rate of 19.3% with plate fixation, though 79.5% are minor complications 5
• Hardware removal rate of 13.4% due to symptomatic hardware, though this does not affect final functional outcome 5, 1

Decision Algorithm

At 4 months post-injury:

1. Obtain clinical assessment for pain, function, and weight-bearing tolerance
2. Consider radiographs if clinical concern for non-union exists
3. If healed clinically and radiographically: Progress to full activities with home exercise program
4. If persistent pain with clinical/radiographic non-union: Proceed with ORIF using locking plate fixation with or without bone graft
5. If healed but functionally limited: Consider short course of supervised therapy for specific deficits

The vast majority of non-operatively treated isolated distal fibula fractures will have healed by 4 months and require only activity progression 1. Surgical intervention should be reserved for the rare cases of symptomatic non-union 3.