What is the initial treatment for an acute nondisplaced transverse fracture of the lateral malleolus with overlying soft tissue swelling?

Initial Treatment for Acute Nondisplaced Transverse Fracture of Lateral Malleolus with Soft Tissue Swelling

Apply a lace-up ankle brace and initiate functional treatment with early mobilization rather than rigid immobilization, as this approach results in faster return to work, better patient satisfaction, and quicker return to sports. 1, 2

Immediate Management

Initial Stabilization and Symptom Control

• Apply cold therapy (ice and water mixture surrounded by a damp cloth) for 20-30 minutes per application to reduce pain and swelling, avoiding direct skin contact to prevent cold injury. 3
• Consider applying a compression wrap after cold therapy to promote comfort, ensuring it does not compromise circulation. 3
• Instruct the patient to avoid activities that cause pain and limit use of the injured extremity. 3

Confirm Diagnosis and Assess Stability

• Obtain weight-bearing radiographs if the patient can tolerate them, as these are critical to determine true stability—a medial clear space <4 mm confirms stability and supports conservative management. 1, 3
• Examine for signs of occult instability including medial tenderness, bruising, or swelling, which indicate associated deltoid or syndesmotic ligament injury requiring different management. 1, 3
• If weight-bearing radiographs reveal medial clear space >4 mm, surgical intervention is required despite the fracture appearing nondisplaced on initial films. 1, 4

Conservative Treatment Protocol

Bracing and Mobilization

• Use a lace-up ankle brace rather than elastic bandage or tape, as it provides superior swelling reduction, fewer complications, and faster functional recovery. 1, 2
• Initiate early mobilization rather than prolonged rigid immobilization—functional treatment is superior for nondisplaced lateral malleolus fractures. 1, 2

Exercise Therapy

• Incorporate exercise therapy into the treatment plan to prevent recurrence and improve long-term outcomes. 1, 2
• Avoid overly aggressive rehabilitation before adequate healing, as this can lead to displacement or nonunion. 1, 2

Follow-Up and Monitoring

Serial Imaging

• 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

Long-Term Surveillance

• Maintain close follow-up, as 5-33% of patients may have persistent pain and instability at 1 year, and 3-34% experience recurrent ankle sprains. 1, 2

Critical Pitfalls to Avoid

Missing Occult Instability

• Failure to obtain weight-bearing radiographs can miss occult instability from associated deltoid or anterior tibiofibular ligament tears, leading to inappropriate conservative management of an unstable fracture. 1
• If medial tenderness or swelling is present despite nondisplaced appearance, consider stress radiographs or gravity stress views to evaluate for deltoid ligament disruption. 1, 3

Inadequate Immobilization

• Do not use elastic bandages or tape as primary treatment—lace-up ankle braces are superior. 1, 2
• Avoid rigid casting for truly stable nondisplaced fractures, as functional treatment produces better outcomes. 1, 2

Premature Weight-Bearing

• Ensure adequate healing before advancing weight-bearing to prevent displacement or nonunion. 1, 2