What is the recommended treatment for a patient with a distal fibular displaced fracture?

Treatment of Distal Fibular Displaced Fractures

For displaced distal fibular fractures, the treatment approach depends critically on fracture stability: stable fractures with medial clear space <4mm can be managed with posterior splinting, while unstable fractures (bi/trimalleolar patterns, syndesmotic injury, or deltoid ligament disruption) require surgical fixation, preferably with open reduction and internal fixation using plate fixation or minimally invasive techniques in high-risk patients. 1

Initial Assessment for Stability

The first critical step is determining fracture stability, which dictates conservative versus operative management:

• Obtain weight-bearing radiographs to assess the medial clear space—if <4mm, the fracture is stable and amenable to conservative treatment 1
• Examine for medial ankle tenderness, bruising, or swelling, which indicates deltoid ligament injury and potential instability requiring surgical consideration 1
• Assess fibular fracture location relative to the syndesmosis—fractures above the syndesmosis carry higher risk of syndesmotic injury 1
• Identify bi- or trimalleolar patterns, which are inherently unstable and typically require surgical fixation 1

Conservative Management for Stable Fractures

For isolated, minimally displaced distal fibular fractures with confirmed stability:

• Apply a posterior splint extending from below the knee to the toes, maintaining the ankle in 90 degrees neutral position to prevent equinus contracture 1
• Maintain initial splinting for approximately 3 weeks with radiographic follow-up to confirm adequate healing 1
• Initiate immediate active toe motion exercises to prevent stiffness, which is one of the most functionally disabling complications 1
• Obtain weight-bearing radiographs at follow-up to reassess the medial clear space and confirm stability 1

Surgical Management for Unstable Fractures

When instability is identified, operative fixation is indicated:

Standard Approach: Plate Fixation

• Open reduction and internal fixation (ORIF) with plate fixation remains the gold standard for displaced unstable ankle fractures, providing anatomic reduction and minimizing posttraumatic arthritis risk 2, 3
• Double plating with two one-third tubular plates is a viable technique for problem fractures requiring enhanced fixation, providing good functional outcomes with FAOS pain scores of 87.6 and ADL scores of 90.4 at 25.6 months 2

Minimally Invasive Alternatives for High-Risk Patients

For elderly patients, those with significant comorbidities, or compromised soft tissue:

• Intramedullary fixation (IMF) is preferred over plate fixation in select high-risk populations, as it results in significantly fewer wound-related complications (OR 0.11), fewer implant removals (OR 0.54), and fewer nonunions (OR 0.31) 4
• Minimally invasive intramedullary nailing has gained popularity for displaced ankle fractures in elderly patients, allowing early weightbearing and minimal soft tissue disruption 3
• Minimally invasive plate osteosynthesis (MIPO) provides excellent functional results with mean AOFAS scores of 88.4 and low complication rates compared to traditional ORIF 5

Postoperative Management

Following surgical fixation:

• Initiate active toe and finger motion exercises immediately to prevent stiffness 1
• Obtain radiographic follow-up at 3 weeks and at time of immobilization removal 1
• Monitor for complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 1

Critical Pitfalls to Avoid

• Do not miss associated injuries: Always examine for medial ankle tenderness (deltoid injury), syndesmotic injury, or Maisonneuve fracture patterns 1
• Do not delay treatment in elderly patients: Left untreated, displaced ankle fractures are associated with increased mortality and morbidity in this population 3
• Do not use traditional ORIF in patients with compromised soft tissue or severe comorbidities: The advantages of minimal soft tissue damage with IMF outweigh the benefits of optimal reduction with plate fixation in these select patients 4
• Do not assume stability without weight-bearing radiographs: Non-weight-bearing films may underestimate instability 1