Treatment of Distal Fibula Fractures
For nondisplaced, stable distal fibula fractures, immobilization is the primary treatment; surgical fixation is indicated when post-reduction displacement exceeds 3mm, dorsal tilt exceeds 10°, or intra-articular involvement is present. 1, 2
Initial Assessment
Before determining treatment, obtain specialized radiographic views beyond standard anteroposterior and lateral films, as these miss 54% of distal fibular avulsion fractures. 1 Key stability indicators include:
- Medial clear space <4mm confirms stability 1
- Assess for concomitant ligamentous injury 1
- Evaluate displacement, intra-articular involvement, and overall fracture stability 2
Treatment Algorithm
Conservative Management (Nondisplaced, Stable Fractures)
Immobilization is the primary approach for minimally displaced fractures without instability. 1 This includes:
- Immediate active finger and toe motion exercises to prevent stiffness, which does not adversely affect adequately stabilized fractures 1, 2
- Ice application at 3 and 5 days post-injury for symptomatic relief 1
- Radiographic follow-up at approximately 3 weeks and at immobilization removal to confirm healing 1, 2
- Monitor for immobilization-related complications (skin irritation, muscle atrophy) which occur in approximately 14.7% of cases 1, 2
Surgical Management Indications
Surgery is mandatory when any of the following criteria are met: 1, 2
- Post-reduction displacement >3mm
- Dorsal tilt >10°
- Intra-articular involvement
Surgical Technique Options
For patients requiring operative fixation, multiple approaches demonstrate excellent outcomes:
- Anatomically contoured locking plates allow immediate full weight-bearing with 100% bone healing at 3 months and no mechanical failures 3
- Minimally invasive techniques (plate osteosynthesis, intramedullary nailing, or IM screw fixation) provide mean American Orthopedic Foot and Ankle Society scores of 88.4 with low complication rates 4
- Intramedullary fixation achieves 98% union rates with average time to union of 10.3 weeks, permitting weight-bearing in a boot at 6.8 weeks 5
- Double plating may be considered for problem fractures requiring enhanced fixation stability 6
- For elderly patients with comorbidities, minimally invasive intramedullary nailing is preferred over traditional open reduction internal fixation to reduce wound complications 7, 4
Common Pitfalls
- Do not rely solely on standard radiographic views—specialized views are essential to avoid missing the fracture 1
- Avoid prolonged immobilization without early motion exercises, as stiffness is functionally disabling 1, 2
- In elderly patients, operative management is increasingly preferred over nonoperative methods, which have been associated with increased mortality 7