A 48-year-old female spectator presents four weeks after “twisting” her right ankle walking to a game. She described localised medial ankle pain and difficult weight bearing. She was seen at an emergency department where an x-ray was said to be normal. As she was still unable to weight-bear two weeks later her family doctor arranged a repeat x-ray. This was also felt to be normal. When she presented for further review, she was able to weight bear without crutches. She had localised tenderness over the medial malleolus.
X-ray images taken at the time of injury (and again two weeks later) do not show any acute bony injury. There is a well-defined lucency in the anterior tibia which is a legacy of old trauma. MRI shows that there is an undisplaced, sagittally oriented, fracture of the medial malleolus. The fracture line extends through to the distal tibial weight-bearing surface without any malalignment. A subsequent CT image shows facture union (as well as quite marked disuse osteopenia).
Due to the delay in diagnosis, the lack of any displacement and the slowly improving symptoms a decision was made to treat this injury non-surgically. The patient used a walking boot for several weeks before progressively coming out of this. While she was able to walk pain-free at this stage she was not able to return to running-based activities for approximately six months. At this point she was entirely asymptomatic and happy with her recovery.
It is often suggested that this type of medial malleolus fracture should be managed with surgical treatment. This is based on the premise that surgery can produce higher rates of union, an earlier return to work or recreational activities, avoid prolonged periods of immobilisation and prevent any residual displacement which may lead to the development of post-traumatic arthritis of the ankle. When the fracture is displaced, or when treating an elite player or physical worker, surgery is likely to be the best option. When the ankle mortise is intact an operation is often not necessary.
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