What is the recommended treatment for a patient with a Weber A fracture of the ankle?

Treatment for Weber A Ankle Fracture

Weber A fractures can be treated conservatively with functional treatment, avoiding immobilization, and allowing early weight-bearing as tolerated. 1

Initial Assessment and Imaging

• Apply the Ottawa Ankle Rules to confirm the need for radiography: obtain ankle radiographs if there is point tenderness over the medial malleolus, posterior edge or inferior tip of the lateral malleolus, or inability to bear weight for 4 steps 2
• Standard radiographic protocol should include three views: anteroposterior, lateral, and mortise views 2
• Weight-bearing radiographs provide critical information about fracture stability, particularly assessing the medial clear space (should be <4 mm to confirm stability) 2

Conservative Treatment Protocol (Primary Approach for Weber A)

Weber A fractures are below the syndesmosis and typically stable, making them suitable for non-operative management 1. The treatment approach should prioritize early mobilization over immobilization:

Immediate Management (First 72 Hours)

• Apply the PRICE protocol: Protection, Rest, Ice, Compression, and Elevation 2
• Use cryotherapy (ice and water mixture surrounded by damp cloth) for 20-30 minutes, 3-4 times daily, avoiding direct skin contact to prevent cold injury 2
• Provide multimodal analgesia starting with scheduled acetaminophen; NSAIDs (such as naproxen or celecoxib) improve pain control, decrease swelling, and enable faster return to activity 2
• Apply compression wrap for comfort, but ensure it does not compromise circulation 2

Functional Treatment (Preferred Over Immobilization)

• Use a walking boot or functional ankle brace rather than rigid immobilization 2, 3
• Functional treatment is superior to immobilization, allowing patients to return to work 7.1 days sooner 2
• Walking boots facilitate faster functional recovery, with patients able to stand unipedal on the injured side in 2.6 weeks versus 4.5 weeks with plaster casts 3
• Allow weight-bearing as tolerated immediately or within the first few days 2, 4

Rehabilitation Protocol

• Begin supervised exercises focusing on proprioception, strength, coordination, and function as soon as pain allows 2
• Start range-of-motion exercises within the first few days to prevent stiffness and muscle atrophy 2
• Supervised exercise programs lead to faster return to sport compared to non-supervised training 2
• Avoid prolonged immobilization, which leads to stiffness and poor functional outcomes 2

When to Consider Orthopedic Referral

• Immediate referral for circulatory compromise, vascular injury, or open fractures 5
• Fractures with medial tenderness, bruising, or swelling suggesting instability 2
• Any concern about syndesmotic injury or fracture stability 2

Common Pitfalls to Avoid

• Do not routinely immobilize Weber A fractures in rigid casts - functional treatment with early mobilization produces superior outcomes 2
• Avoid tight compression that compromises circulation 2
• Do not apply heat in the acute phase 2
• Avoid manipulation of the ankle prior to radiographs unless there is neurovascular deficit or critical skin injury 2
• Do not delay rehabilitation - early functional exercises are critical for optimal recovery 2

Expected Recovery Timeline

• Full weight-bearing typically achieved by 7 weeks with functional treatment 4
• Return to work expected around 8-9 weeks 4
• Most patients achieve good functional outcomes (Olerud scores >85 points) with appropriate conservative management 4