From the Guidelines
An avulsed, displaced fracture of the medial malleolus requires urgent orthopedic consultation for surgical fixation. This injury occurs when the medial ankle bone (part of the tibia) breaks and displaces from its normal position, often due to an ankle eversion injury or rotation force. Initial management includes immobilization with a posterior splint, elevation of the extremity above heart level, ice application for 20 minutes every 2-3 hours, and appropriate pain control with medications such as acetaminophen 1000mg every 6 hours and/or ibuprofen 600mg every 6 hours if not contraindicated.
- Key considerations for management include:
- Immobilization to prevent further injury
- Elevation and ice to reduce swelling and pain
- Pain control to improve patient comfort
- Urgent orthopedic consultation for surgical planning Weight-bearing should be avoided until surgical evaluation. Surgery typically involves open reduction and internal fixation (ORIF) with screws or plates to restore anatomical alignment, as supported by the general principles of fracture management, although the specific details for this condition are not directly addressed in the provided study 1. This surgical approach is necessary because displaced medial malleolar fractures often lead to ankle instability and post-traumatic arthritis if not properly reduced. Post-operative care generally includes 6-8 weeks of limited weight-bearing with gradual progression to full weight-bearing as healing progresses, followed by physical therapy to restore range of motion, strength, and proprioception. Complications without proper treatment may include malunion, nonunion, ankle instability, and accelerated osteoarthritis.
From the Research
Avulsed, Displaced Fracture of the Medial Malleolus
- The treatment of avulsed, displaced fractures of the medial malleolus is a topic of ongoing debate in the medical community 2, 3, 4.
- Studies have shown that operative fixation of medial malleolar fractures can lead to better outcomes in terms of fracture healing and functional recovery 2, 5.
- However, the decision to operate on a medial malleolar fracture depends on various factors, including the size and displacement of the fracture, as well as the patient's overall health and activity level 3, 6.
- A systematic review of 18 studies found that surgical treatment of isolated medial malleolar fractures resulted in a lower nonunion rate compared to conservative treatment, but functional outcomes were similar between the two groups 3.
- Another study found that closed reduction and percutaneous internal fixation was an effective and minimally invasive method for treating medial malleolus fractures, with all patients achieving bone union and good functional outcomes 5.
- A recent study suggested that not all medial malleolar fractures require fixation, and that the decision to operate should be based on the fracture pattern and patient selection 6.
Treatment Options
- Operative fixation: This involves surgically reducing and stabilizing the fracture using internal fixation devices such as screws or plates 2, 5, 4.
- Conservative treatment: This involves non-surgical management of the fracture, including immobilization and physical therapy 3.
- Percutaneous fixation: This involves using a minimally invasive approach to stabilize the fracture using percutaneous screws or wires 2, 5.
Outcomes
- Fracture healing: Operative fixation has been shown to result in higher rates of fracture healing compared to conservative treatment 2, 3.
- Functional outcomes: Functional outcomes have been shown to be similar between operative and conservative treatment groups 3.
- Pain: The presence of pain after treatment has been shown to vary depending on the fracture pattern and treatment approach 6.