What is the appropriate management for a medial malleolus fracture that already shows callus formation on X‑ray?

Management of Medial Malleolus Fracture with Callus Formation

A medial malleolus fracture showing callus formation on X-ray indicates the fracture is already healing and should be managed conservatively with protected weight-bearing, serial radiographic monitoring, and functional rehabilitation rather than surgical intervention.

Understanding Callus Formation

Callus formation on X-ray indicates the fracture has entered the reparative phase of bone healing, typically occurring 2-3 weeks post-injury. At this stage, surgical intervention is generally contraindicated unless there is evidence of malunion with functional impairment or persistent instability.

Initial Assessment Required

• Obtain standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) to evaluate current alignment and healing progress 1
• Measure the medial clear space on mortise views—a measurement <4mm confirms stability and appropriate healing 1, 2
• If weight-bearing is tolerated, obtain weight-bearing radiographs to assess dynamic stability, as these provide critical information about functional alignment 3, 2
• Consider MRI without IV contrast only if radiographs are inconclusive regarding soft tissue healing or if there are concerns about associated ligamentous injuries 2

Conservative Management Protocol

Since callus formation indicates active healing, proceed with the following approach:

• Continue protected weight-bearing with a walking boot or ankle brace, progressing as tolerated based on pain and stability 1
• Initiate early mobilization with functional treatment, as this improves outcomes compared to prolonged immobilization 3
• Implement structured rehabilitation to prevent chronic instability and recurrent injuries 3

Radiographic Follow-Up Schedule

• Obtain serial radiographs at 2,6, and 12 weeks from initial presentation to confirm maintenance of alignment and progressive fracture healing 3
• Continue radiographic monitoring until complete union is documented, as regular follow-up is essential to ensure proper healing 1, 2
• Use MRI to confirm complete healing only in cases where radiographs remain inconclusive 2

When Surgery Would Still Be Indicated

Surgery at this stage would only be appropriate if:

• The fracture shows malunion with >2mm displacement causing functional impairment or joint incongruity 3
• Weight-bearing radiographs demonstrate persistent instability with medial clear space >4mm despite callus formation 3, 1
• There is evidence of nonunion rather than healing callus (though this would be unusual with visible callus) 4

Critical Pitfalls to Avoid

• Do not operate on a healing fracture with callus formation unless there is clear malunion or instability, as disrupting the healing process can lead to worse outcomes 3
• Avoid overly aggressive rehabilitation before adequate healing, which can lead to displacement or delayed union 1
• Do not miss associated ligamentous injuries (particularly deltoid ligament disruption) that may require additional treatment even if the fracture is healing 3, 1
• Ensure adequate assessment for syndesmotic injury, which may need separate management 3
• Monitor patients with osteoporosis more closely, as they may require extended protection 2

Expected Timeline

• Most medial malleolus fractures heal within 6-8 weeks with appropriate conservative management 5
• Full return to activity typically occurs by 8-12 weeks if healing progresses normally 3
• Continue monitoring for at least 12 weeks to ensure complete union and rule out late complications 3