Session IV - Foot & Ankle

Nonoperative Treatment of Isolated Medial Malleolus Fractures

Dolfi Herscovici, Jr., DO; Julia M. Sucaduto, ARNP; Roy W. Sanders, MD; Anthony Infante, Jr., DO; Thomas DiPasquale, DO, Tampa General Hospital, Tampa, FL

Purpose: The goal in treating ankle fractures is to obtain an anatomic reduction of the mortise. The purpose of this study was to determine whether surgical management is necessary for patients with isolated medial malleolus fractures.

Methods: From January, 1992 through December, 1999, 67 patients with isolated medial malleolus fractures (40 right and 27 left) were enrolled. There were 29 women and 38 men with an average age of 39.7 years (range, 17 to 69). Fractures were classified into four patterns: type A, avulsion at the distal tip; type B, fracture between the tip and the plafond; type C, at the level of the plafond; and type D, extending vertically above the plafond. Patients were excluded if they had open growth plates, previously operated malleolar injuries, bimalleolar or trimalleolar fractures, injuries involving the plafond, impaction, neoplasms, infections, or open fractures. Displacement was measured on plain radiographs. The treatment protocol consisted of immobilization in a nonweight-bearing cast for 6 weeks followed by physical therapy. Patients were followed for a minimum of 6 months and were assessed radiographically to determine union or complications. Patients were evaluated clinically with the AOFOS foot and ankle scores and were asked to complete the SF-36 form.

Results: Follow-up averaged 24.1 months (range, 6 to 82). Three patients refused follow-up and 9 died, leaving 55 patients available for follow-up. There were 10 type-A, 6 type-B, 29 type-C, and 10 type-D fractures with displacement averaging 2.5 mm (range, 1 to 11 mm). Fifty-three (96%) fractures healed as a result of the index treatment. At follow-up, radiographs demonstrated an anatomic reduction of the mortise without the development of any posttraumatic arthritis. Clinically, patients demonstrated an arc of dorsi- and plantarflexion averaging 38° (range, 26 to 64) with AOFOS scores averaging 87 (range, 66 to 100). Surgical management was required for two nonunions, both occurring in type C injuries. No other complications were noted.

Discussion: The traditional method of treatment for isolated medial malleolar injuries is operative. In this series of patients, nonoperative management resulted in a healing rate of 96% with an anatomic reduction of the mortise and no increase in the rate of arthritis. Good motion was obtained and functional outcomes appeared to equal those of populations treated operatively. Care must be taken to differentiate these injuries from plafond or impaction injuries.

Conclusion: Excluding injuries of the plafond or those producing instability of the mortise, patients presenting with isolated medial malleolar fractures can be successfully treated noperatively. If painful nonunions develop, surgery is indicated.