What type of splint or boot is recommended for a malleolar fracture?

Malleolar Fracture Splinting Recommendations

For malleolar fractures pending orthopedic evaluation, apply a well-padded posterior splint or short leg splint with the ankle positioned at 90 degrees (neutral position) if this can be achieved comfortably, or splint in the position found if the fracture is significantly deformed. 1

Immediate Assessment and Splinting Approach

Check for Vascular Compromise First

• Immediately assess if the extremity is blue, purple, or pale—this indicates limb-threatening injury requiring immediate EMS activation. 2, 1
• Document pulses, capillary refill, and sensation before and after splint application. 1
• Cover any open wounds with a clean dressing before splinting to reduce contamination risk. 1

Positioning Strategy

The key principle is to splint in the position found unless the ankle can be comfortably positioned at neutral (90 degrees). 2, 1

• Do not attempt to straighten or move a deformed fracture—this can cause neurovascular injury and has no proven benefit. 2
• If the ankle can be positioned comfortably, neutral (90 degrees) is preferred because it minimizes tension on neurovascular structures, prevents equinus contracture, and facilitates subsequent surgical planning. 1
• Avoid plantarflexion positioning—this increases posterior displacement of the talus and can worsen posterior malleolar fragment displacement. 1
• Avoid dorsiflexion positioning—this creates excessive tension that can compromise anterior neurovascular structures and increase soft tissue swelling. 1

Splint Type and Application

Recommended Splint Options

• Posterior splint (sugar-tong splint) or short leg splint are the standard options for malleolar fractures. 1
• The splint should be well-padded to cushion the injury and prevent pressure points. 2
• Apply the splint comfortably tight and snug, but allow a finger to be slipped under it to ensure adequate circulation. 2

Critical Pitfalls to Avoid

• Do not force the ankle into any specific position if significant resistance or deformity is present—splint in the position found. 2, 1
• Do not delay transport attempting to achieve perfect positioning—the primary goal is to reduce pain and prevent further injury during transport. 1
• Avoid excessive padding that could mask developing compartment syndrome—malleolar fractures are often high-energy injuries with significant soft tissue trauma requiring compartment syndrome monitoring. 1

Weight-Bearing Status

• The patient should not bear weight on the injured extremity until advised by an orthopedic specialist. 2
• This is critical regardless of splint type, as premature weight-bearing can displace fracture fragments.