Nonoperative Management of Bimalleolar Ankle Fractures

Initial Assessment and Immobilization

The American College of Foot and Ankle Surgeons recommends obtaining weightbearing radiographs to assess dynamic stability, which is the gold standard for determining if nonoperative treatment is appropriate, in patients with bimalleolar ankle fractures 1, 2
Measurement of medial clear space on mortise views is crucial, and a value of ≤4mm is required to confirm stability, according to the Orthopaedic Trauma Association 1, 2
Any displacement >2mm mandates surgical intervention, regardless of other factors, as stated by the American Academy of Orthopaedic Surgeons 1

The British Society of Sports Medicine recommends transitioning to functional support (ankle brace) for 2-4 additional weeks after 6 weeks of casting, to provide optimal outcomes 3, 4, 5
Functional support for 4-6 weeks total is recommended, as it provides better outcomes compared to prolonged rigid immobilization, according to the British Journal of Sports Medicine 3, 4, 5
The use of an ankle brace allows protected loading while preventing rigid immobilization complications, as suggested by the National Institute for Health and Care Excellence 3, 4

Failure to obtain weightbearing radiographs initially can lead to incorrect assessment of stability, and regular follow-up radiographs are necessary to confirm maintenance of reduction, as recommended by the American College of Radiology 1, 2
Inadequate radiographic follow-up can result in late instability, and associated deltoid ligament disruption must be assessed, according to the European Society of Foot and Ankle Surgeons 1, 2
Excessive immobilization beyond 6 weeks can lead to stiffness and poor outcomes, and transition to functional support is necessary, as stated by the British Society of Sports Medicine 3, 4, 5