Initial Treatment for Mildly Displaced Distal Fibula Fracture
Apply a posterior splint extending from below the knee to the toes with the ankle at 90 degrees (neutral position) and initiate immediate active toe motion exercises. 1
Immediate Immobilization Protocol
Use a posterior splint that extends from below the knee to the toes, maintaining the ankle in neutral position (90 degrees) to prevent equinus contracture and accommodate anticipated swelling in the first 48-72 hours 1
The American College of Radiology specifically recommends this approach for isolated, minimally displaced distal fibular fractures 1
This splinting technique is preferred over rigid casting for stable fractures, allowing for swelling management while providing adequate stabilization 1
Critical Assessment Before Splinting
Before proceeding with conservative management, you must rule out instability indicators:
Check the medial clear space on weight-bearing radiographs - if less than 4mm, the fracture is stable and appropriate for conservative management 1
Examine for medial tenderness, bruising, or swelling - these findings suggest deltoid ligament injury and potential instability requiring surgical consideration rather than splinting alone 1
Identify the fracture level - fibular fractures above the syndesmosis carry higher risk of syndesmotic injury and may require different management 1
Rule out bi- or trimalleolar patterns - these are inherently unstable and typically require surgical fixation 1
Essential Active Motion Protocol
Initiate immediate active toe motion exercises from the time of diagnosis to prevent stiffness, which is one of the most functionally disabling complications 1
Active toe motion does not adversely affect adequately stabilized fractures and is critical for preventing long-term disability 1
This differs from wrist motion, which is not routinely necessary following stable fracture fixation 2
Duration and Follow-up Timeline
Maintain initial splinting for approximately 3 weeks with radiographic follow-up to confirm adequate healing 1
Obtain weight-bearing radiographs at follow-up to provide critical information about fracture stability, particularly reassessing the medial clear space 1
Radiographic evaluation should occur at approximately 3 weeks post-immobilization and again at the time of immobilization removal 1
Common Pitfalls to Avoid
Do not miss associated injuries - always examine for medial ankle tenderness, syndesmotic injury, or Maisonneuve fracture patterns even when the fibular fracture appears isolated 1
Monitor for immobilization complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of cases 1
Avoid over-immobilization - excessive immobilization leads to stiffness that can be difficult to treat after fracture healing and may require multiple therapy visits or additional surgical intervention 3
When Conservative Management Fails
While the evidence shows that stable isolated type B fibula fractures with medial clear space ≤6mm have equivalent long-term outcomes with non-operative versus operative treatment at 5-year follow-up 4, surgical intervention becomes necessary if:
- Instability is demonstrated on weight-bearing radiographs 1
- Medial clear space exceeds 4mm 1
- Open fracture or high-energy mechanism is present 1
- Progressive displacement occurs during follow-up 1
Note that surgical management carries a 33% rate of revision surgery for implant removal and 3% risk of wound infection requiring IV antibiotics 4, making conservative management preferable when stability criteria are met.