What is the recommended non‑operative management for a nondisplaced fibular fracture?

Non-Operative Management of Nondisplaced Fibular Fractures

Nondisplaced fibular fractures should be treated non-operatively with immobilization, early weight-bearing as tolerated, and functional rehabilitation, as more than 90% achieve excellent outcomes without surgery when the ankle mortise remains stable. 1

Initial Stability Assessment

The critical first step is confirming ankle mortise stability, which determines whether non-operative management is appropriate:

• Verify medial clear space ≤6 mm on radiographs – this confirms deltoid ligament integrity and ankle stability 2
• Assess for displacement – nondisplaced fractures with stable mortise can be managed conservatively 1, 3
• Consider stress radiographs or weight-bearing films if stability is questionable, as these improve diagnostic accuracy 1

Immobilization Protocol

Rigid immobilization is essential for preventing displacement and promoting healing:

• Use a rigid splint or cast rather than removable devices, particularly if any degree of displacement exists 4
• Duration typically ranges 4-6 weeks, individualized based on clinical and radiographic healing 4
• Avoid inadequate immobilization as this increases risk of displacement and nonunion 4

Weight-Bearing Strategy

• Progressive weight-bearing as tolerated should begin early within the constraints of immobilization 1, 3
• Full weight-bearing is generally safe once initial pain subsides, typically within 1-2 weeks 3
• Non-weight bearing protocols are not necessary for stable, nondisplaced fractures and may delay recovery 5

Rehabilitation Program

Early mobilization and structured physical therapy optimize functional outcomes:

• Begin range of motion exercises at 7-10 days within pain tolerance to prevent stiffness 6
• Initiate passive range of motion under physiotherapy supervision during early mobilization phase 6
• Progress to resistance exercises focusing on ankle stabilizers and proprioception 6
• Continue exercises for minimum 6 months to ensure complete functional recovery 4

Pain Management

• Acetaminophen scheduled dosing as first-line for pain control 6
• Short-term opioids only if necessary for breakthrough pain 6
• Avoid NSAIDs due to potential interference with bone healing 6

Radiographic Monitoring

Serial imaging is mandatory to detect early displacement:

• Repeat X-rays at 1-2 weeks to identify any loss of reduction 6
• Follow-up imaging at 6 weeks to confirm healing progression 6
• Monitor for persistent fracture line or widening which may indicate nonunion 7

Red Flags Requiring Surgical Conversion

Immediate surgical consultation is indicated if:

• Gross displacement develops during treatment 6
• Medial clear space widens >6 mm indicating deltoid incompetence 2
• Persistent localized pain with reproducible tenderness at fracture site beyond 8-12 weeks suggests nonunion 7
• Antalgic gait persists despite appropriate conservative treatment 7

Secondary Fracture Prevention

All patients require osteoporosis evaluation, particularly those >50 years:

• Order DEXA scan, vitamin D, calcium, and PTH levels for all fragility fractures 6, 5
• Initiate bisphosphonate therapy when indicated for osteoporosis 6
• Ensure adequate calcium and vitamin D supplementation as non-pharmacological prevention 8
• Implement fall prevention strategies including balance training 8

Expected Outcomes

Non-operative treatment yields excellent results when stability criteria are met:

• 89% achieve good or excellent Olerud-Molander scores at long-term follow-up 3
• Long-term function and pain scores are equivalent or superior to operative treatment in stable fractures 2
• Fibular displacement after treatment does not affect functional outcomes if mortise remains stable 3
• Nonunion rate is low (<5%) but requires vigilance for persistent symptoms 7

Common Pitfalls to Avoid

• Failing to assess ankle mortise stability leads to inappropriate non-operative treatment of unstable fractures 1
• Inadequate immobilization increases displacement and nonunion risk 4
• Missing symptomatic nonunion – persistent lateral ankle pain with reproducible tenderness warrants repeat imaging 7
• Neglecting osteoporosis evaluation in patients >50 years misses opportunity for secondary fracture prevention 8