Treatment of Distal Fibula Fracture in 2 Places
For an adult or adolescent with a distal fibula fracture in 2 places, treatment depends critically on ankle stability: stable fractures can be managed conservatively with removable splinting for 3 weeks, while unstable fractures require surgical fixation with open reduction and internal fixation (ORIF). 1, 2
Initial Assessment: Determining Stability
The most important criterion in treatment of malleolar fractures is stability 1. Assess the following:
- Medial clear space on weight-bearing radiographs (if possible): <4 mm confirms stability 1, 2
- Clinical indicators of instability: medial tenderness, bruising, or swelling; fibular fracture above the syndesmosis; bi- or trimalleolar fractures; open fracture; or high-energy mechanism 1
- Radiographic displacement criteria: radial shortening >3mm, dorsal tilt >10°, or intra-articular displacement indicate need for surgical fixation 3, 2
Common pitfall: Standard anteroposterior and lateral radiographs miss 54% of distal fibular avulsion fractures, so specialized views may be needed 2. Obtain anteroposterior, lateral, and mortise views including the base of the fifth metatarsal 1.
Conservative Management (Stable, Minimally Displaced Fractures)
For fractures meeting stability criteria:
- Immobilization: Removable splinting for 3 weeks 3, 4, 2
- Immediate finger/toe motion exercises: Begin active motion exercises immediately to prevent stiffness, which is one of the most functionally disabling complications 3, 4, 2
- Ice application: Apply at 3 and 5 days post-injury for symptomatic relief 2
- Radiographic follow-up: At approximately 3 weeks and at immobilization removal to confirm healing 4, 2
- Monitor for complications: Skin irritation or muscle atrophy occur in approximately 14.7% of immobilization cases 4, 2
Surgical Management (Unstable or Displaced Fractures)
When instability is present or displacement exceeds criteria above, surgical fixation is indicated 1, 3, 2:
Surgical Options:
- Standard ORIF with plate fixation: Traditional approach using lateral anatomically contoured locking plates allows immediate full weight-bearing with 100% bone healing rates at 3 months 5
- Double plating: For complex or comminuted fractures in 2 places, using two one-third tubular plates provides enhanced fixation stability with excellent functional outcomes 6
- Minimally invasive techniques: Intramedullary nailing or minimally invasive plate osteosynthesis show excellent functional results (mean AOFAS scores 88.4) with lower wound complication rates compared to traditional ORIF 7
Post-Operative Protocol:
- Immobilization duration: Limit to 1-3 weeks maximum following surgical fixation, as early mobilization produces equal or better outcomes than prolonged immobilization 3
- Weight-bearing: Modern locking plate constructs allow immediate full weight-bearing 5
- Immediate finger/toe exercises: Begin active motion exercises immediately post-operatively 3, 2
Critical pitfall: Do not use prolonged external fixation beyond 3 weeks, as studies show poorer outcomes with extended fixation 3.
Adjunctive Treatment
- Vitamin C supplementation: Consider for prevention of disproportionate pain (moderate recommendation strength from AAOS) 3, 4
Special Considerations for Multiple Fracture Sites
For a fibula fractured "in 2 places" (comminuted or segmental pattern):
- Enhanced fixation may be needed: Double plating provides stouter fixation to decrease risk of fixation failure in complex fracture patterns 6
- Minimally invasive intramedullary nailing: Particularly useful in elderly or high-risk patients with comminuted fractures, allowing early weight-bearing with minimal soft tissue disruption 8, 7