Does an isolated, closed, minimally displaced fibular fracture without neurovascular injury require hospital admission?

Does Fibular Fracture Need Admission?

No, an isolated, closed, minimally displaced fibular fracture without neurovascular injury does not require hospital admission and can be safely managed as an outpatient with conservative treatment.

Key Decision Factors

The decision to admit depends on several critical factors that must be systematically assessed:

Fracture Stability Assessment

• Medial clear space ≤6 mm on standard radiographs indicates stability and allows for safe outpatient management 1, 2
• If medial clear space widening is present or uncertain, stress radiographs should be obtained to assess for mortise instability 1, 3
• Isolated distal fibular fractures with confirmed ankle stability have excellent outcomes with conservative treatment 1, 2

Indications for Admission (When Present)

While the evidence focuses primarily on hip and major fragility fractures requiring multidisciplinary orthogeriatric care 4, these principles do NOT apply to simple fibular fractures. Admission would only be warranted if:

• Open fracture requiring operative washout 4
• Neurovascular compromise requiring urgent intervention
• Proven ankle instability (widened medial clear space >6 mm or positive stress views) requiring surgical fixation 1, 2
• Inability to manage pain as an outpatient despite appropriate analgesia
• Social factors preventing safe discharge (inability to mobilize, lack of support)

Outpatient Management Protocol

Immediate Pain Control

• Regular paracetamol (acetaminophen) as first-line analgesia 5
• Cautiously titrated opioids if paracetamol insufficient, with attention to renal function 4, 5
• Avoid NSAIDs until renal function confirmed, as approximately 40% of fracture patients have moderate renal dysfunction 4, 5

Immobilization

• Removable cast or walking boot for stable fractures 1
• Weight-bearing as tolerated based on pain 1

Follow-up

• Outpatient orthopedic follow-up within 1-2 weeks to reassess clinical and radiographic alignment 1
• Consider telehealth follow-up when appropriate to minimize unnecessary visits 4

Evidence Supporting Outpatient Management

A 2019 retrospective cohort study with 5.3-year mean follow-up demonstrated that isolated type B fibular fractures with medial clear space ≤6 mm treated non-operatively had equivalent long-term outcomes to surgical treatment (OMAS score 84 vs 84, p=0.98; AOFAS 93 vs 90, p=0.28), while avoiding surgical risks including 33% revision surgery rate for implant removal and 3% wound infection rate 2.

Critical Pitfalls to Avoid

• Do not miss ankle instability: Always assess medial clear space and obtain stress views if any doubt exists 1, 3
• Do not prescribe NSAIDs without checking renal function first 4, 5
• Do not assume all fibular fractures are benign: The anterior inferior tibiofibular ligament suffers complete interruption in every case of isolated fibular fracture with widened medial clear space on stress views 3
• Do not delay appropriate surgical referral if instability is confirmed 1, 2