Treatment of Fibular Styloid Fracture
For isolated, non-displaced fibular styloid fractures, rigid immobilization with a cast or boot is the recommended treatment, as surgical fixation has not been shown to improve patient outcomes. 1
Initial Assessment and Decision-Making
The critical first step is determining whether the fibular styloid fracture is isolated or associated with a distal radius fracture, as this fundamentally changes management. 1
Key Stability Indicators to Assess:
- Displacement status - non-displaced fractures can be managed conservatively 2, 3
- Associated syndesmotic injury - requires surgical fixation if present 2, 3
- Medial clear space on radiographs - should be <4 mm to confirm stability 1
- Presence of medial tenderness, bruising, or swelling - suggests instability 1
Treatment Algorithm
Non-Operative Management (Preferred for Most Cases)
Rigid immobilization is the treatment of choice for non-displaced fibular styloid fractures. 2, 3
- Apply a cast or removable boot for stable, non-displaced fractures 2, 3
- Begin active finger and toe motion exercises immediately to prevent stiffness 3, 4
- Apply ice at 3 and 5 days post-injury for symptomatic relief 4
- Consider vitamin C supplementation to prevent disproportionate pain (moderate strength recommendation) 4
- Consider low-intensity ultrasound for short-term pain improvement, though long-term benefits are unproven 4
Surgical Management (Reserved for Specific Indications)
Surgery is indicated only when specific instability criteria are met: 2, 3
- Associated syndesmotic injury present - this is the most critical indication 2, 3, 5
- Fracture-dislocation of the ankle 5
- Fibular fracture above the syndesmosis level with ankle instability 6, 5
- Open fractures 5
Surgical technique when indicated:
- Plate osteosynthesis is the standard approach with a 99.5% union rate 7
- Syndesmotic screw fixation is needed in 72% of cases with associated injuries 5
- Do not remove syndesmotic screws until fibular fracture shows radiographic healing (average 9 weeks) to avoid diastasis 5
- Consider bone grafting in high-energy fractures with comminution 5
Follow-Up Protocol
- Radiographic follow-up at 3 weeks to assess healing and rule out secondary displacement 3, 4
- Additional imaging at time of immobilization removal to confirm adequate healing 3
- Physical therapy for range of motion and strengthening after immobilization period 2, 3
- Monitor for complications including skin irritation, muscle atrophy, and stiffness 3
Critical Pitfalls to Avoid
The most important caveat: when a fibular styloid fracture occurs with a distal radius fracture, the American Academy of Orthopaedic Surgeons states there is insufficient evidence to recommend for or against fixation of the styloid fracture. 1 Studies show no difference in radiographic appearance or patient outcomes between fixation and non-fixation when the radius is properly managed. 1
Failure to identify associated syndesmotic injuries is the most common error leading to poor outcomes and may require additional surgical intervention. 3, 5
Early removal of syndesmotic screws before fibular healing can lead to diastasis of the distal tibiofibular joint - two patients in one series developed occult nonunions after premature screw removal. 5
Inadequate reduction of unstable fractures leads to malunion, post-traumatic arthritis, and poor functional outcomes. 3
Expected Outcomes
With appropriate non-operative management, healing occurs in 2.7 to 4.0 months (average 3.2 months). 8 When surgery is required, plate fixation achieves a 99.5% union rate with a 19.3% overall complication rate, of which 79.5% are minor complications. 7 The reoperation rate for hardware-related symptoms is 13.4% for hardware removal. 7