What is the treatment for a Weber type B ankle fracture?

Weber Type B Ankle Fracture Treatment

For stable Weber B ankle fractures, functional bracing with immediate weight-bearing as tolerated is the treatment of choice, providing equivalent outcomes to casting with superior comfort and faster return to function. 1, 2, 3, 4

Initial Assessment and Stability Determination

• Obtain standard ankle radiographs to assess fracture displacement, ankle mortise congruity, and talocrural angle alignment 1
• Consider CT imaging if posterior malleolar involvement or syndesmotic injury is suspected, as plain films miss these injuries despite CT having near 100% sensitivity 1
• Immediate surgical referral is mandatory for deltoid ligament rupture or vascular compromise (blue, purple, or pale extremity) 1

Treatment Algorithm for Stable Weber B Fractures

Non-Operative Management (First-Line for Stable Fractures)

Immobilization Duration:

• Three weeks of immobilization is non-inferior to six weeks for stable Weber B fractures, with mean Olerud-Molander Ankle Scores of 91.7 versus 87.6 at one year (difference 3.6 points, 95% CI -1.9 to 9.1) 2
• Functional bracing demonstrates superior comfort (VAS 7.21 vs 5.74, p=0.02) and range of motion (49° vs 40°, p=0.00) at six weeks compared to casting 3

Immobilization Method:

• Removable ankle brace is preferred over rigid casting for stable fractures, showing equivalent functional outcomes with reduced complications and fewer clinic visits 1, 3, 4
• Weight-bearing as tolerated should begin immediately with functional bracing 4
• If using casting initially, transition to functional brace after one week 3

Pain Management:

• NSAIDs are first-line: naproxen 500mg twice daily or celecoxib for pain control and improved function 1

Surgical Treatment Indications

Absolute indications for open reduction and internal fixation:

• Unstable fractures with ankle mortise incongruency 5
• Deltoid ligament rupture 1
• Vascular compromise 1
• Displacement during conservative treatment (occurs in approximately 2.4% of cases) 4

Surgical technique when indicated:

• Pre-contoured distal fibular locking plate is the preferred fixation method for Weber B fractures, achieving 86.67% satisfactory outcomes with mean AOFAS scores of 88.67 6
• Mean radiological healing time is 12.7 weeks with surgical fixation 6

Rehabilitation Protocol

Immediate Phase (0-3 weeks):

• Exercise therapy should begin immediately after initial immobilization to prevent recurrence (risk ratio 0.37 for recurrent injury) 1
• Continue functional support throughout this period 1

Recovery Phase (3-6 weeks):

• Functional support reduces return to work time by 8.23 days compared to immobilization 1
• Return to sport occurs 4.88 days earlier with functional treatment 1

Monitoring and Complications

Follow-up schedule:

• Clinical assessment at 1,6, and 12 weeks 2, 3
• Radiographs only if clinical concern for displacement arises 4

Complications to monitor:

• Cast-associated skin breakdown occurs in 14% of high-risk patients 1
• Deep vein thrombosis risk is reduced with functional bracing versus casting 2
• Compartment syndrome or neurovascular compromise requires immediate assessment 1
• Displacement requiring surgery occurs in approximately 2.4% of conservatively managed stable fractures 4

Key Clinical Pitfalls

• Avoid prolonged immobilization beyond 3 weeks for stable fractures, as it provides no additional benefit and increases joint stiffness 2, 3
• Do not routinely obtain serial radiographs in stable fractures without clinical concern, as this increases cost without improving outcomes 4
• Ensure true stability before functional bracing: any mortise incongruency, deltoid ligament injury, or syndesmotic disruption requires surgical evaluation 1, 5