4,10 Early mechanical testing suggested that the lateral talar displacement of as little as 1 mm would significantly increase contact pressures in the tibiotalar joint, thus creating a potential predisposition to early arthritic changes. 24,28–30Īlternatively, an argument may be made for repairing all but nondisplaced fibular fractures, the rationale being that even small increments of displacement may lead to fibular shortening or mortise widening. Clinical studies have supported this notion, demonstrating good results with up to 30-year follow-up on nonoperative treatment of isolated lateral malleolar fractures. 18 This implies that the distal fibula maintains its relationship with the mortise and that no functional incongruity is present ( Fig. 1,10–19,26,27 It also has been shown by CT analysis that fibular displacement occurring as a result of an external rotation force with intact medial structures (Lauge-Hansen SER2) is the result of internal rotation of the proximal fragment. 22–25,26 Physiologic loading studies of the normal and compromised ankle suggest that the medial structures are, in fact, most important for stability.
Several studies support displacement, lateral or posterior, of up to 5 mm without significant compromise in clinical outcomes. Intact medial structures, specifically the malleolus and deltoid ligament, provide primary resistance to lateral talar translation, thus limiting or preventing abnormal ankle mechanics. On one hand, arguments may be made that surgery is unnecessary because, even though the lateral stability is compromised, it is not completely diminished. 15,21,22,23 However, fibular fractures at any level without concomitant injury or significant radiographic displacement generate varied and controversial opinions as to what is considered appropriate intervention.
Associated syndesmosis widening or medial injury, bony or ligamentous, make the choice of treatment fairly simple and obvious. Isolated lateral malleolar fractures present one of the most challenging management dilemmas in the realm of sports injuries. McGarvey, in Baxter's the Foot and Ankle in Sport (Second Edition), 2008 Lateral fractures