Would a walking boot be suitable for a nondisplaced lateral malleolus fracture?

Walking Boot for Nondisplaced Lateral Malleolus Fracture

Yes, a walking boot (ankle-foot orthosis) is appropriate for a nondisplaced lateral malleolus fracture, but only after confirming stability with weight-bearing radiographs showing a medial clear space <4 mm. 1

Initial Stability Assessment Required

Before recommending any immobilization device, you must first confirm the fracture is truly stable:

• Obtain weight-bearing radiographs to measure the medial clear space – this is the critical step that determines your entire treatment pathway 1
• A medial clear space <4 mm confirms stability and supports conservative management with functional treatment 1
• A medial clear space >4 mm indicates instability requiring surgical intervention, regardless of how "nondisplaced" the fracture appears 1
• Assess for signs of associated ligamentous injury: medial tenderness, bruising, swelling, or fibular fracture above the syndesmosis all suggest instability 1

Optimal Conservative Treatment Approach

Once stability is confirmed, functional treatment is superior to rigid immobilization:

• Use a lace-up ankle brace rather than a walking boot, elastic bandage, or tape – this provides better swelling reduction, fewer complications, and faster functional recovery 1
• Functional treatment with early mobilization results in faster return to work, better patient satisfaction, and quicker return to sports compared to rigid immobilization 1
• Incorporate exercise therapy into the treatment plan to prevent recurrence and improve long-term outcomes 1

Walking Boot as Alternative

If a walking boot is used instead of a lace-up brace:

• Mobilization with partial weight-bearing (15-20 kg) in an ankle-foot orthosis (walking boot) for 6-8 weeks is acceptable 2
• The boot should allow for ankle motion exercises, which should begin early in the treatment course 3
• Immediate weight-bearing as tolerated is safe and beneficial, shortening hospital stay and time to return to work without increasing complications 3

Critical Follow-Up Requirements

• Obtain serial radiographs to confirm maintenance of alignment and assess healing progression 1
• Monitor for delayed union or nonunion, though this is rare in nondisplaced fractures treated conservatively 1
• Be aware that 5-33% of patients may have persistent pain and instability at 1 year, and 3-34% experience recurrent ankle sprains 1

Common Pitfalls to Avoid

• Failure to obtain weight-bearing radiographs is the most critical error – this can miss occult instability from associated deltoid or anterior tibiofibular ligament tears, leading to inappropriate conservative management of an unstable fracture 1
• Missing associated ligamentous injuries compromises outcomes – if medial tenderness or swelling is present, consider stress radiographs to evaluate for deltoid ligament disruption 1, 4
• Overly aggressive rehabilitation before adequate healing can lead to displacement or nonunion 1
• Isolated lateral malleolus fractures are only stable if no other ligaments are torn; stress radiographs may be necessary to demonstrate talar instability 4