Management of Medial Malleolus Fracture with Ankle Support
For a medial malleolus fracture, ankle support alone is insufficient—these fractures require orthopedic evaluation for surgical fixation, as non-operative management with bracing is reserved only for truly non-displaced fractures with an intact ankle mortise. 1
Critical Initial Assessment
Obtain standard ankle radiographs (AP, lateral, mortise views) immediately to assess:
- Degree of displacement of the medial malleolar fragment 1
- Integrity of the lateral malleolus and posterior malleolus (ruling out bimalleolar or trimalleolar fracture) 1
- Congruency of the ankle mortise and joint line 1
- Width of the medial clear space (>4mm suggests deltoid ligament injury) 1
A displaced fracture of only the medial malleolus must be accompanied by either deltoid or syndesmotic ligament injury, creating instability that requires surgical fixation. 1
When Ankle Support May Be Appropriate (Rare)
Ankle support is appropriate only for truly non-displaced medial malleolar fractures (<2mm displacement) with:
- Intact ankle mortise on all three radiographic views 1
- No widening of the medial clear space 1
- No associated lateral or posterior malleolar injury 1
- Ability to maintain reduction on repeat radiographs at 5-7 days 2
If these criteria are met, use a semi-rigid ankle brace or walking boot for 4-6 weeks with:
- Non-weight-bearing or touch-down weight-bearing for the first 2-3 weeks 2
- Serial radiographs at 1 week, 2 weeks, and 4 weeks to confirm maintained alignment 2
- Transition to protected weight-bearing in the brace once early callus is visible 2
Why Most Medial Malleolar Fractures Require Surgery
When there are two breaks in the ankle mortise ring (medial malleolus plus lateral ligament injury, or bimalleolar fracture), the potential for displacement exists even after successful closed reduction, making operative treatment the preferred option. 1
Surgical fixation with rigid internal fixation allows:
- Early ankle motion to prevent stiffness 1
- Anatomic restoration of the joint surface 1
- Lower non-union rates (2% with headless compression screws vs. up to 20% with conservative treatment) 3
- Reduced need for hardware removal (2% with headless screws vs. frequent removal with traditional screws) 3
Immediate Orthopedic Referral Indications
Refer immediately to orthopedics for:
- Any displacement >2mm on initial radiographs 1
- Widening of the medial clear space suggesting deltoid incompetence 1
- Bimalleolar or trimalleolar fracture patterns 1
- Inability to maintain reduction on follow-up films 2
- Fracture involving >25% of the tibial plafond (higher risk of post-traumatic arthritis) 1
- High-demand athletes (stress fractures in this population require surgical fixation to prevent recurrence) 4
Common Pitfalls to Avoid
Do not assume an isolated medial malleolar fracture is stable—it must be accompanied by lateral ligamentous injury or lateral malleolar fracture to occur. 1 Failure to recognize this creates risk of progressive displacement and chronic instability.
Do not rely on ankle support alone for displaced fractures—non-union rates up to 20% have been reported with conservative management of displaced medial malleolar fractures. 3
Do not miss concomitant peroneal tendon dislocation in patients with isolated medial malleolar fractures, as this rare injury pattern requires surgical repair of both structures. 5
Obtain repeat radiographs at 5-7 days for any fracture managed non-operatively, as delayed displacement can occur and necessitates conversion to surgical fixation. 2
Biomechanical Considerations
In high-demand athletes with recurrent medial malleolar stress fractures, address underlying biomechanical factors including:
- Varus limb malalignment (cavovarus foot deformity) 4
- Custom-made foot orthoses to correct alignment 4
- Evaluation for chronic anteromedial impingement 4
- Assessment of ankle instability 4
Surgical treatment combined with orthotic support yields successful outcomes when biomechanical factors are addressed. 4