Is a 49-year-old male with a minimal displaced oblique Weber type B distal fibular fracture stable for orthopedic (ortho) evaluation or should he be directed to the emergency department (ED)?

Management of Minimally Displaced Weber Type B Distal Fibular Fracture

This patient is stable for outpatient orthopedic follow-up and does not require emergency department transfer. 1

Immediate Urgent Care Management

Ensure adequate immobilization with a posterior splint or walking boot to stabilize the fracture. 1 The key determinant for safe conservative management versus ED transfer is the presence or absence of vascular compromise, severe bleeding, or inability to maintain adequate immobilization. 1

Critical Assessment Points

Perform and document the following before discharge:

• Neurovascular examination: Confirm distal pulses, capillary refill, and intact sensation—any compromise mandates immediate ED transfer. 1
• Medial ankle examination: Palpate for medial malleolar tenderness, swelling, or ecchymosis, which suggests deltoid ligament injury and potential instability. 2
• Weight-bearing status: Document whether the patient can bear weight, though this alone does not exclude significant injury. 3
• Skin integrity: Ensure no open wounds or skin compromise. 3

Disposition Decision Algorithm

Send to ED if ANY of the following are present:

• Vascular compromise or absent distal pulses 1
• Severe bleeding or open fracture 1
• Inability to achieve adequate immobilization 1
• Suspected syndesmotic injury (proximal fibular tenderness, high fibular fracture) 2
• Bimalleolar or trimalleolar fracture pattern 2

Safe for Orthopedic Outpatient Follow-up if ALL of the following:

• Well-perfused extremity with normal neurovascular examination 1
• Adequate immobilization achieved 1
• Minimal displacement on radiographs 2
• No medial tenderness or swelling suggesting deltoid injury 2

Outpatient Management Plan

Schedule orthopedic consultation within 1-2 weeks for definitive treatment planning. 1 Approximately 47-53% of these fractures may ultimately require surgical intervention, but this determination can be made at the orthopedic follow-up. 1

Prescribe:

• Immobilization: Posterior splint or walking boot with strict non-weight-bearing or touch-down weight-bearing initially 1
• Analgesia: Acetaminophen scheduled dosing; use opioids cautiously if needed for breakthrough pain 1
• Anticoagulation: Consider VTE prophylaxis if prolonged immobilization expected, particularly in higher-risk patients 4

Patient Instructions:

• Elevate leg above heart level to reduce swelling 1
• Ice application 20 minutes every 2-3 hours for first 48-72 hours
• Return immediately for increased pain, numbness, tingling, color changes, or inability to move toes 1

Common Pitfalls to Avoid

Do not over-triage stable fractures to the ED when appropriate outpatient orthopedic follow-up with adequate immobilization is available. 1 Many surgeons unnecessarily treat Weber B fractures operatively without proven medial instability. 2 The medial clear space measurement on mortise radiographs is critical—values >4mm suggest instability, but additional diagnostics like MRI or gravity stress views may be needed to differentiate stable from unstable fractures when the medial clear space is 4-6mm. 2

Ensure documentation of distal pulses and perfusion to avoid missing vascular injury. 1 The ability to walk does not exclude serious fracture, as patients with minimally displaced fractures can maintain initial weight-bearing ability. 3

Verify adequate immobilization of both the ankle mortise and distal fibula before discharge. 1 Inadequate immobilization is a primary reason for ED transfer and can lead to displacement and complications. 1