Medial malleolus fracture

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This 31-year-old professional female player presented following an acute injury to her right ankle. The injury occurred in a tackle. She was uncertain about the exact mechanism but remembers a heavy blow to her ankle followed by immediate medial ankle pain and an inability to continue. On examination she is unable to weight-bear, had localised tenderness over the medial ankle and had pain with all ankle movements. There was no tenderness about the proximal fibula.

An x-ray of the ankle demonstrated an isolated fracture of the medial malleolus. The fracture is displaced and has a transverse orientation. The displacement is best demonstrated on the oblique view.

This player was managed with open reduction and internal fixation. She was then managed in a walking boot for a period of six weeks. From this point she was able to start a progressive rehabilitation programme involving cycling-based activity, a jogging programme and a return to football activities. During this time she had physiotherapy treatments to improve her ankle range of motion, to restore ankle strength and to improve her proprioception. She was able to return to full training approximately four months following her injury. At this stage there was some ongoing discomfort and stiffness however this was relatively modest and continued to improve.

Isolated medial malleolus fractures are relatively rare. These fractures are more commonly associated with injuries to the fibula. It is especially important to consider whether there may be an injury to the proximal fibula (a Maisonneuve fracture). It is important to assess for this by palpating the proximal fibula and obtaining x-rays of this region if there is clinical concern. In some cases isolated, non-displaced medial malleolar fractures can be treated in a below knee walking cast or boot. Where there is displacement, or when there is an associated bimalleolar or trimalleolar fracture, surgery should be performed. Surgery should also be considered for most elite players as it is likely that this will give a more predictable outcome and a more rapid recovery.

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