What is the best approach for splinting a patient with a distal fibular fracture?

Management of Distal Fibular Fracture with Splinting

For isolated, minimally displaced distal fibular fractures, apply a posterior splint extending from below the knee to the toes with the ankle maintained at 90 degrees (neutral position), and maintain this immobilization for approximately 3 weeks with radiographic follow-up. 1

Splint Application Technique

• Position the ankle at 90 degrees during splint application to prevent equinus contracture and accommodate anticipated swelling during the first 48-72 hours 1
• The posterior splint should extend from below the knee to the toes, providing adequate immobilization of the ankle joint 1
• Ensure the splint is padded and comfortably snug but not constrictive—you should be able to slip a finger underneath 2

Critical Assessment Before Splinting

Before proceeding with conservative splint management, you must rule out features indicating instability that would require surgical referral rather than splinting alone:

• Check for medial ankle tenderness, bruising, or swelling, which suggests deltoid ligament injury and potential instability requiring surgical consideration 1
• Assess the medial clear space on weight-bearing radiographs—stability is indicated by less than 4mm spacing 1
• Identify if the fibular fracture is above the syndesmosis, which indicates higher risk of syndesmotic injury 1
• Rule out bi- or trimalleolar fractures, which are inherently unstable and typically require surgical fixation 1
• Examine for open fractures or high-energy mechanisms warranting immediate orthopedic consultation 1

Immediate Active Motion Protocol

• Initiate active toe motion exercises immediately to prevent stiffness, which is one of the most functionally disabling complications 1
• Active motion of uninvolved joints does not adversely affect adequately stabilized fractures 1, 2
• This is critical—over-immobilization leads to stiffness that can be extremely difficult to treat and may require multiple therapy visits or surgical intervention 2

Duration and Follow-Up Schedule

• Maintain initial splinting for approximately 3 weeks 1
• Obtain radiographic follow-up at 3 weeks to confirm adequate healing and assess alignment 1
• Weight-bearing radiographs at follow-up provide critical information about fracture stability, particularly for assessing the medial clear space 1

Common Pitfalls to Avoid

• Do not miss associated injuries: Always examine for medial ankle tenderness, syndesmotic injury, or Maisonneuve fracture pattern 1
• Monitor for complications including skin irritation and muscle atrophy, which occur in approximately 14.7% of immobilization cases 1
• Avoid immobilizing joints unnecessarily—only the ankle requires immobilization, not the knee or toes beyond what the splint naturally covers 3
• Do not use rigid casting for minimally displaced fractures when a posterior splint is sufficient 3