From the Guidelines
Management of malleolar fractures in the emergency department should begin with a thorough assessment, including neurovascular status, soft tissue evaluation, and appropriate imaging, as outlined in the American College of Radiology's Appropriateness Criteria for acute trauma to the ankle 1. The initial assessment should include evaluation of the patient's ability to bear weight and the presence of point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, as these are indicators for further imaging according to the Ottawa Ankle Rules 1. Key considerations in the management of malleolar fractures include:
- Immobilization with a posterior splint or removable boot for stable, non-displaced fractures
- Non-weight bearing status, elevation, and ice application to reduce swelling
- Pain management with acetaminophen and/or ibuprofen, with stronger options like oxycodone for severe pain
- Orthopedic consultation for potential surgical fixation in cases of unstable or displaced fractures
- Immediate orthopedic intervention, tetanus prophylaxis, and intravenous antibiotics for open fractures
- Education on elevation, ice application, monitoring for compartment syndrome, and strict adherence to weight-bearing restrictions to optimize healing outcomes. The American College of Radiology's Appropriateness Criteria for acute trauma to the ankle 1 provides guidance on the use of radiography, including the importance of weight-bearing radiographs, if possible, to assess fracture stability. In terms of specific imaging protocols, the criteria recommend three standard views: anteroposterior, lateral, and mortise views, and note that special scenarios, such as suspected calcaneal fractures or snowboarder's fracture, may require additional views 1. Overall, the goal of management is to prevent further displacement and soft tissue damage, while ensuring appropriate definitive management based on fracture stability, displacement, and joint involvement, with the ultimate goal of optimizing healing outcomes and minimizing morbidity, mortality, and impact on quality of life.
From the Research
Video Malleolar Fracture Management in the Emergency Department
- The management of malleolar fractures in the emergency department involves stabilization of the fracture with a splint and careful assessment of neurovascular status 2.
- Trimalleolar fractures are unstable and almost always require surgical repair, even in elderly patients and those with co-morbidities 2.
- The classification of malleolar fractures according to Lauge-Hansen or Weber can help determine the indication for nonoperative or operative treatment 3.
- For isolated lateral malleolar fractures, conservative treatment is indicated for most Weber A fractures and 80% of Weber B fractures 3.
- Surgical treatment is recommended for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures 3.
Factors Influencing Treatment
- The size of the posterior malleolar fragment does not significantly affect the outcome of ankle fractures, and the decision to treat these fractures should be determined by other factors such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation 4.
- For isolated medial malleolar fractures, conservative treatment is safe for fractures displaced ≤2 mm, but further research is needed to determine the best treatment for fractures displaced >2 mm 5.
- The evaluation and management of foot and ankle pain in the emergency department require a thorough history and physical examination, as well as focused imaging to determine the stability of the injury and the need for operative intervention 6.
Treatment Options
- Surgical treatment is often necessary for unstable malleolar fractures, while conservative treatment may be sufficient for stable fractures 2, 3, 5.
- The choice of treatment for isolated medial malleolar fractures displaced >2 mm may depend on patient characteristics and demands, highlighting the need for further research 5.