Ankle Fracture: What Your Injured Ankle Needs to Heal

Ankle Fracture: What Your Injured Ankle Needs to Heal

Introduction & Epidemiology

Ankle fractures represent a significant burden on public health and orthopedic practice, accounting for approximately 10-15% of all adult fractures. These injuries range from isolated, non-displaced malleolar fractures to complex fracture-dislocations involving multiple malleoli and the syndesmosis. The rising incidence is attributed to an aging population susceptible to low-energy falls, coupled with increasing participation in high-impact sports among younger individuals.

While the provided seed content highlights the prevalence of physeal injuries in the ankle in pediatric populations, noting that distal fibula physeal injuries account for 58% of all ankle physeal injuries, this comprehensive review will primarily focus on adult malleolar fractures, which constitute the vast majority of cases managed by orthopedic surgeons. Anatomically, the ankle joint is a critical weight-bearing articulation, and disruption of its intricate bony and ligamentous architecture can lead to profound functional impairment if not appropriately managed.

Classification systems, such as Lauge-Hansen and Danis-Weber, are instrumental in understanding injury mechanisms, predicting fracture patterns, and guiding treatment strategies. Lauge-Hansen describes fractures based on the position of the foot at the time of injury and the deforming force (e.g., supination-adduction, supination-external rotation, pronation-abduction, pronation-external rotation). The Danis-Weber classification categorizes fibular fractures relative to the level of the syndesmosis (Type A: below, Type B: at the level, Type C: above). Both systems aid in assessing ankle stability and determining the need for operative intervention. The primary goal of treatment, whether operative or non-operative, is to achieve and maintain an anatomical reduction of the ankle mortise to prevent long-term sequelae such as post-traumatic arthritis and chronic instability.

Surgical Anatomy & Biomechanics

A thorough understanding of the complex anatomy and biomechanics of the ankle joint is paramount for successful management of ankle fractures. The ankle is a hinge joint formed by the distal tibia (plafond, medial malleolus, posterior malleolus), the distal fibula (lateral malleolus), and the talus.

Bony Anatomy

• Distal Tibia:
  • Tibial Plafond: The inferior articular surface of the tibia, concave in the anteroposterior dimension and slightly convex mediolaterally. It articulates with the trochlea of the talus. Its integrity is crucial for load distribution.
  • Medial Malleolus: The distal projection of the tibia medially, providing medial stability and attachment for the deltoid ligament. Its posterior aspect often includes the posterior colliculus, with the anterior colliculus providing the attachment point for the superficial deltoid ligament.
  • Posterior Malleolus: The posterior aspect of the tibial plafond. Fractures involving this structure are clinically significant, especially if they encompass a substantial portion of the articular surface, due to their impact on joint stability and potential for posterior talar subluxation.
• Distal Fibula:
  • Lateral Malleolus: The distal projection of the fibula laterally, extending more distally and posteriorly than the medial malleolus. It forms the lateral wall of the ankle mortise and is critical for lateral stability, serving as the attachment site for the lateral collateral ligaments. The fibular incisura of the tibia accommodates the distal fibula.
• Talus: The body of the talus forms the central component of the ankle mortise, articulating with the tibial plafond superiorly and the medial and lateral malleoli medially and laterally, respectively. Its trochlear surface is wider anteriorly than posteriorly, contributing to ankle stability in dorsiflexion.

Ligamentous Anatomy

The stability of the ankle mortise is maintained by a robust network of ligaments.

• Lateral Collateral Ligaments: Comprise three distinct bands that originate from the lateral malleolus.
  • Anterior Talofibular Ligament (ATFL): Originates from the anterior border of the lateral malleolus and inserts into the lateral talar neck. It is the weakest and most commonly injured lateral ligament, restricting anterior talar displacement and inversion in plantarflexion.
  • Posterior Talofibular Ligament (PTFL): Originates from the posterior aspect of the lateral malleolus and inserts into the posterior process of the talus. It is the strongest of the lateral ligaments, preventing posterior talar displacement and extreme dorsiflexion.
  • Calcaneofibular Ligament (CFL): Originates from the tip of the lateral malleolus and inserts into the lateral surface of the calcaneus. It resists talar inversion and serves as a critical secondary stabilizer.
• Medial Collateral (Deltoid) Ligament: A broad, fan-shaped ligament on the medial aspect, divided into superficial and deep components.
  • Superficial Deltoid: Composed of the tibionavicular, tibiocalcaneal, and superficial posterior tibiotalar ligaments. These primarily resist eversion and external rotation.
  • Deep Deltoid: Consists of the anterior and posterior tibiotalar ligaments. These are intra-articular and stronger, resisting talar external rotation and valgus tilt. The deep deltoid is a crucial stabilizer, and its integrity is often assessed by the medial clear space on radiographs.
• Syndesmosis: A critical fibrous joint between the distal tibia and fibula, maintaining the integrity of the ankle mortise. It consists of:
  • Anterior Inferior Tibiofibular Ligament (AITFL): A weak, flat band extending from the anterior tubercle of the tibia to the anterior aspect of the lateral malleolus.
  • Posterior Inferior Tibiofibular Ligament (PITFL): A stronger ligament extending from the posterior tubercle of the tibia to the posterior aspect of the lateral malleolus. Its deep fibers form the transverse tibiofibular ligament (TTFL).
  • Interosseous Membrane (IOM): Extends proximally from the syndesmosis, contributing to tibiofibular stability.

Biomechanics

The ankle mortise functions as a highly congruent articulation, where the talar body fits snugly between the malleoli. The stability of this mortise is dependent on both bony architecture and ligamentous integrity. Approximately 90% of the axial load across the ankle is transmitted through the tibia, with the fibula bearing the remaining 10%.
The fibula's length relative to the tibia and its stable articulation with the tibia via the syndesmosis are critical for maintaining the lateral wall of the mortise. A 1mm lateral shift of the talus within the mortise can decrease the contact area by up to 42%, significantly increasing joint stress and leading to premature degenerative changes.

During ankle dorsiflexion, the wider anterior talus engages the malleoli, increasing bony stability. In plantarflexion, the narrower posterior talus allows for greater motion and reliance on ligamentous support. Ankle fractures typically occur due to rotational and axial forces, leading to predictable patterns of injury. For instance, supination-external rotation injuries, the most common type, typically involve a spiral fracture of the fibula (Weber B), often associated with rupture of the ATFL and/or a deep deltoid ligament injury, and potentially a posterior malleolar fracture. Pronation-external rotation injuries tend to cause higher fibular fractures (Weber C) and syndesmotic disruption.

Indications & Contraindications

The decision to pursue operative versus non-operative management of ankle fractures hinges on the stability of the ankle mortise, the degree of displacement, the involvement of articular surfaces, and patient-specific factors. The primary objective is to restore and maintain anatomical alignment to optimize long-term function and minimize post-traumatic arthrosis.

Operative Indications

Operative intervention, typically open reduction and internal fixation (ORIF), is generally indicated for unstable ankle fractures. Instability can be manifest by bony displacement or ligamentous disruption that cannot be adequately controlled by non-operative means.

• Displaced Bimalleolar Fractures: Fractures involving both the medial and lateral malleoli, irrespective of syndesmotic integrity, are inherently unstable.
• Displaced Trimalleolar Fractures: Fractures involving the medial, lateral, and posterior malleoli. These are highly unstable and often involve significant articular surface disruption.
• Displaced Unimalleolar Fractures with Associated Instability:
  • Lateral Malleolus Fracture: If displaced and associated with medial clear space widening (>4mm on AP or mortise views), indicating deep deltoid ligament rupture or medial malleolus fracture, and/or syndesmotic disruption.
  • Medial Malleolus Fracture: If displaced, particularly with associated talar shift or lateral ligamentous injury.
  • Posterior Malleolus Fracture: If the fragment involves >25-30% of the articular surface of the tibial plafond, or if it results in demonstrable posterior talar subluxation, even with smaller fragments. Some surgeons advocate for fixation of smaller fragments if they are displaced and represent a significant portion of the weight-bearing posterolateral aspect.
• Syndesmotic Disruption (Diastasis): Regardless of malleolar fracture pattern, if the syndesmosis is unstable and diastasis is present (e.g., increased tibiofibular clear space >6mm, tibiofibular overlap <6mm on AP, or tibiofibular clear space >5mm on mortise view, or positive intraoperative stress test).
• Open Fractures: Require urgent irrigation, debridement, and stabilization to prevent infection and facilitate soft tissue healing.
• Fracture-Dislocations: Ankle dislocations almost invariably imply significant ligamentous and/or bony injury requiring operative stabilization following reduction.
• Failure of Closed Reduction or Inability to Maintain Reduction: If closed reduction fails to achieve anatomical alignment or if initial non-operative management cannot maintain a stable reduction.
• Articular Incongruity: Any articular step-off or gap greater than 2mm, particularly in the weight-bearing dome of the talus, significantly increases the risk of post-traumatic arthritis.

Non-Operative Indications

Non-operative management typically involves closed reduction (if necessary), immobilization (cast or boot), and protected weight-bearing.

• Stable Unimalleolar Fractures:
  • Lateral Malleolus Fracture (Weber A or B): Non-displaced or minimally displaced, without medial clear space widening, talar shift, or syndesmotic instability.
  • Medial Malleolus Fracture: Non-displaced avulsion fractures, or stable, minimally displaced fractures without talar shift.
• Stress Fractures: Managed symptomatically with protected weight-bearing and activity modification.
• Patients with Significant Medical Comorbidities: Those with severe cardiopulmonary disease, uncontrolled diabetes, or other conditions that significantly increase the risks of anesthesia and surgery, making them poor surgical candidates. The decision here is often a risk-benefit analysis, weighing the functional outcome against surgical mortality/morbidity.
• Non-Ambulatory or Limited Ambulation Patients: In some cases, for patients with pre-existing severe mobility limitations, the functional benefit of surgery may not outweigh the risks.

Contraindications

Absolute Contraindications:

• Severe Soft Tissue Compromise: Extensive skin blistering, necrotic tissue, or severe swelling that precludes safe incision and closure. Delaying surgery in such cases to allow for soft tissue recovery is crucial, often managed with temporary external fixation.
• Active Infection: Cellulitis or osteomyelitis in the surgical field.
• Irreparable Neurovascular Injury: Although rare, a non-reconstructible vascular injury might necessitate amputation rather than limb salvage.

Relative Contraindications:

• Severe Peripheral Vascular Disease: Increased risk of wound healing complications and infection.
• Poorly Controlled Diabetes Mellitus: Associated with neuropathy, increased infection risk, and impaired wound healing.
• Severe Osteoporosis: May compromise implant purchase and stability, leading to fixation failure. Specialized techniques or implants may be required.
• Neuropathic Arthropathy (Charcot Joint): Presents significant challenges for fixation and healing.

Operative vs. Non-Operative Indications Summary

Pre-Operative Planning & Patient Positioning

Careful pre-operative planning is essential for predictable outcomes in ankle fracture surgery, encompassing diagnostic imaging, soft tissue assessment, patient optimization, and precise surgical execution.

Pre-Operative Assessment and Imaging

• History and Physical Examination: A thorough history detailing the mechanism of injury, prior ankle pathology, and medical comorbidities is crucial. Physical examination focuses on neurovascular status, soft tissue integrity (presence of swelling, blistering, open wounds, skin tenting), and assessment of deformity.
• Radiographic Series: Standard ankle radiographs include anteroposterior (AP), lateral, and mortise views.
  • AP View: Assesses medial clear space, tibiofibular clear space, tibiofibular overlap.
  • Lateral View: Evaluates posterior malleolus fractures, talar displacement (anterior/posterior subluxation), and overall sagittal alignment.
  • Mortise View (15-20° internal rotation): Optimal for evaluating the ankle mortise, medial clear space, and syndesmotic integrity by opening the joint.
• Computed Tomography (CT) Scan: Indicated for complex fractures, especially those involving the posterior malleolus to quantify fragment size and displacement, comminuted distal tibial plafond fractures, severe articular step-off, or when surgical planning requires a detailed three-dimensional assessment of fracture morphology. It is particularly useful for assessing syndesmotic reduction post-fixation.
• Magnetic Resonance Imaging (MRI): Rarely indicated acutely for routine ankle fractures. May be considered in cases of suspected chondral injury, occult ligamentous injuries, or to differentiate between soft tissue and bony pathology if diagnosis remains unclear despite radiographs and CT.
• Vascular Assessment: For patients with significant peripheral vascular disease or suspected vascular compromise, ankle-brachial index (ABI) and potentially angiography or CTA may be warranted.
• Soft Tissue Envelope: Critical assessment of swelling, skin integrity, and presence of fracture blisters. Significant swelling or impending skin necrosis necessitates delaying definitive fixation, often managed with temporizing measures such as splinting, elevation, and ice, with definitive surgery postponed until the "wrinkle sign" returns. External fixation may be used in cases of severe soft tissue compromise or open fractures awaiting delayed definitive fixation.

Pre-Operative Planning

• Fracture Classification and Pattern Analysis: Using Lauge-Hansen and Danis-Weber classifications guides understanding of the forces involved and likely associated injuries.
• Implant Selection: Based on fracture pattern, bone quality, and surgeon preference. Options include various plates (1/3 tubular, locking, anatomical contoured, anti-glide), screws (cortical, cancellous, headless, syndesmotic), and sometimes intramedullary nails for fibular fractures.
• Approach Planning: Anticipate necessary incisions to access all fracture fragments, considering internervous planes and avoiding neurovascular structures.
• Contingency Planning: Always have backup plans for potential intraoperative challenges (e.g., bone loss, comminution, difficulty with reduction, implant failure).
• Antibiotic Prophylaxis: Administer pre-operatively, typically within one hour of incision, adhering to hospital protocols.
• DVT Prophylaxis: Assess patient risk factors and initiate appropriate prophylaxis.

Patient Positioning

• Supine Position: The most common position for ankle fracture ORIF.
• Ipsilateral Hip Bump: A bump placed under the ipsilateral hip allows the leg to externally rotate, facilitating access to the lateral malleolus and syndesmosis.
• Thigh Tourniquet: A pneumatic tourniquet placed high on the thigh is routinely used to provide a bloodless field, crucial for visualization and precise reduction.
• C-arm Fluoroscopy: Essential for intraoperative radiographic assessment of reduction and hardware placement. The C-arm should be draped and positioned to allow for AP, lateral, and mortise views without repositioning the patient or the foot.
• Leg Holder/Support: The limb should be positioned in a way that allows easy manipulation for reduction maneuvers and provides stable support during fixation. A sterile support beneath the calf can be helpful.

Detailed Surgical Approach / Technique

The goal of ankle fracture fixation is anatomical reduction and stable internal fixation of all fractured components, with particular attention to restoring the ankle mortise and syndesmotic integrity.

General Principles

• Anatomical Reduction: Crucial for preventing post-traumatic arthritis. A step-off or gap >2mm is unacceptable.
• Stable Fixation: Achieved with appropriate hardware and technique, allowing for early rehabilitation.
• Soft Tissue Protection: Meticulous handling of skin and soft tissues is paramount to minimize wound complications.
• Restoration of Mortise: Primary focus, often achieved by addressing the lateral malleolus first.

Lateral Malleolus Fixation

The lateral malleolus is often addressed first as its length and rotation are critical for the overall ankle mortise.

• Approach: A longitudinal incision centered over the distal fibula, typically 10-15 cm in length. It can be anterolateral (between peroneus tertius and superficial peroneal nerve) or posterolateral (between peroneus brevis/longus anteriorly and sural nerve/peroneal tendons posteriorly). The choice depends on the fracture pattern and associated posterior malleolus involvement. The superficial peroneal nerve should be identified and protected in the anterolateral approach. The sural nerve and lesser saphenous vein should be identified and protected in the posterolateral approach.
• Dissection: Subcutaneous dissection to raise full-thickness fasciocutaneous flaps, exposing the fibula. Avoid wide undermining to protect the blood supply to the skin. The peroneus brevis and longus tendons are retracted posteriorly to access the fibula.
• Reduction: Direct reduction of the fibula fracture is achieved using anatomical clamps (e.g., Verbrugge, pointed reduction forceps) placed carefully to avoid comminution. The fibular length and rotation are crucial. Restore the fibula to its fibular incisura.
• Fixation:
  • Lag Screw + Neutralization Plate: For spiral or oblique fractures (Weber B, C), a lag screw is placed across the fracture site for interfragmentary compression. This is then protected by a neutralization plate (e.g., 1/3 tubular, semi-tubular, or pre-contoured locking plate) applied to the lateral or posterior aspect of the fibula. The plate should span at least 6 cortices proximal and 4 cortices distal to the fracture, with at least two screws in each main fragment.
  • Antiglide Plate: For short oblique or transverse fractures, a plate placed posterolaterally can buttress the fibula against posterior displacement.
  • Intramedullary Nailing: Less common, reserved for highly comminuted fibular fractures, poor bone quality, or in cases where extensive plate exposure is undesirable.

Medial Malleolus Fixation

• Approach: A longitudinal incision, typically 4-6 cm, centered over the medial malleolus. It is usually placed anterior to the posterior tibial tendon sheath and posterior to the saphenous vein and nerve.
• Dissection: Subcutaneous dissection, carefully identifying and protecting the saphenous nerve and vein. The posterior tibial tendon sheath is identified. The fracture site is exposed.
• Reduction: Direct reduction of the medial malleolus fragment, often using pointed reduction clamps. Ensure no interposed soft tissue (e.g., deltoid ligament, posterior tibial tendon) blocking reduction.
• Fixation:
  • Two Partially Threaded Cancellous Screws: The most common method. Screws are inserted from the tip of the medial malleolus into the tibial plafond, providing interfragmentary compression. Angle them slightly anteriorly to capture more distal tibia and avoid the articular surface.
  • Tension Band Wiring: For small, comminuted avulsion fractures where screw purchase is poor. K-wires are placed across the fracture, and a figure-of-eight wire loop converts tensile forces into compressive forces.
  • Plate Fixation: Rarely used for medial malleolus due to prominent hardware and soft tissue coverage issues, but may be indicated for larger, comminuted fragments or revision surgery.

Posterior Malleolus Fixation

The decision to fix the posterior malleolus depends on its size (typically >25-30% of the articular surface), displacement, and associated talar subluxation.

• Approach:
  • Anteroposterior (AP) Screws: Can be placed percutaneously or through the primary fibular incision, aiming from anterior tibia into the posterior fragment. Less invasive but reduction is indirect.
  • Posterolateral Approach (e.g., Henry's or modification): Incision between the Achilles tendon and the peroneal tendons. Accesses the posterolateral aspect of the distal tibia and fibula. Requires careful retraction of the peroneal tendons and sural nerve. Good for direct visualization of the posterolateral fragment.
  • Posteromedial Approach: Incision between the posterior tibial tendon and flexor hallucis longus tendon. Provides access to the posteromedial malleolus. Careful protection of the posterior tibial neurovascular bundle (flexor digitorum longus, posterior tibial artery, nerve, flexor hallucis longus).
• Dissection: For posterior approaches, careful identification and protection of the posterior tibial neurovascular bundle is critical.
• Reduction: Direct visualization and reduction using reduction clamps or bone hooks. Indirect reduction via ligamentotaxis (e.g., through a fibular reduction) can be attempted for smaller fragments.
• Fixation:
  • AP Screws: Two or three fully or partially threaded cancellous screws placed from anterior to posterior across the fracture.
  • Posterior Buttress Plate: For larger or comminuted fragments, a small fragment plate (e.g., 1/4 tubular or anatomical plate) can be applied to the posterior aspect of the tibia to buttress the reduction.

Syndesmotic Fixation

Syndesmotic injury implies disruption of the tibiofibular syndesmosis, leading to widening of the ankle mortise and talar instability. Assessment is critical.

• Intraoperative Assessment: After malleolar fixation, the stability of the syndesmosis is assessed.
  • Hook Test: An instrument is used to externally rotate the fibula, assessing for excessive motion.
  • Cotton Test: External rotation stress applied to the foot with the ankle in dorsiflexion, looking for widening of the syndesmosis on fluoroscopy.
  • Stress Views: AP and mortise views with external rotation stress to evaluate tibiofibular clear space and overlap.
• Reduction: The syndesmosis must be anatomically reduced before fixation. A reduction clamp (e.g., Weber clamp) is applied from anterior to posterior or medial to lateral across the tibia and fibula, ensuring the fibula is seated appropriately in the fibular incisura of the tibia. The ankle should be in neutral dorsiflexion or slight dorsiflexion to account for the wider anterior talus and prevent over-compression.
• Fixation:
  • Cortical Screws: Typically one or two 3.5mm or 4.5mm cortical screws placed 2-4 cm above the ankle joint line, traversing 3-4 cortices. The number and size of screws are debated. Screws can be removed at 8-12 weeks, especially in active patients, to prevent breakage and allow physiological motion, though data supporting routine removal is mixed.
  • Suture Button Device (e.g., TightRope®): A newer dynamic fixation technique involving a high-strength suture looped through buttons on either side of the syndesmosis. It allows for micro-motion and physiological loading, potentially reducing the need for hardware removal. It is becoming increasingly popular.

Complications & Management

Despite meticulous surgical technique, complications following ankle fracture ORIF can occur, necessitating a comprehensive understanding of their incidence and management strategies.

General Surgical Complications

• Infection:
  • Superficial: Incidence 5-10%. Managed with wound care, oral antibiotics.
  • Deep: Incidence 1-5%. Requires surgical debridement, irrigation, intravenous antibiotics, and potentially hardware removal and reimplantation. May lead to osteomyelitis.
• Wound Dehiscence/Skin Necrosis: Incidence 2-5%. Higher in patients with diabetes, PVD, smoking. Managed with local wound care, negative pressure wound therapy (NPWT), or surgical debridement and flap coverage in severe cases.
• Neurovascular Injury: Rare (<1%). Damage to superficial peroneal, sural, or saphenous nerves. Management involves protection during surgery, neurolysis, or observation for recovery. Vascular injury requires immediate repair.
• Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE): Incidence 1-5% for DVT, <1% for PE. Prophylaxis (mechanical, pharmacological) is crucial. Treatment involves anticoagulation.
• Complex Regional Pain Syndrome (CRPS): Incidence 1-5%. Characterized by disproportionate pain, swelling, and autonomic dysfunction. Management is multidisciplinary, including physical therapy, medications (gabapentin, tricyclics), nerve blocks, and psychological support.

Specific Ankle Fracture Complications

| Complication | Incidence (%) | Management Strategies |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and patient factors) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Malunion (deformity causing symptoms) | Varies by fracture type and definition | Non-surgical: Activity modification, orthotics, shoe wear modification, physical therapy for pain management.
Surgical: Corrective osteotomy (e.g., fibular, tibial), joint preservation procedures (e.g., arthroscopy for impingement), or ultimately arthrodesis/arthroplasty if severe arthrosis develops. |

| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and patient factors) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Post-traumatic Arthritis | 50-70% (severity varies, usually within 10-20 years) | Conservative: Activity modification, NSAIDs, orthotics, intra-articular injections (corticosteroids, hyaluronic acid).
Surgical (Joint Preservation): Arthroscopic debridement, osteochondral grafting (for focal defects), realignment osteotomies.
Surgical (Salvage): Ankle arthrodesis (fusion) for severe, painful, end-stage arthritis; Total ankle arthroplasty (replacement) for selected patients with lower activity demands and good bone stock. |
| Syndesmotic Malreduction | 5-20% (can be subtle or obvious) | Conservative: Non-weight-bearing, immobilization for stable non-operative cases.
Surgical: Revision syndesmotic fixation with anatomical reduction. May involve hardware removal, debridement of fibrous tissue, and re-fixation with screws or suture button. For chronic cases, arthrodesis may be considered. |
| Malunion (deformity causing symptoms) | Varies by fracture type and definition | Non-surgical: Activity modification, orthotics, shoe wear modification, physical therapy for pain management.
Surgical: Corrective osteotomy (e.g., fibular, tibial), joint preservation procedures (e.g., arthroscopy for impingement), or ultimately arthrodesis/arthroplasty if severe arthrosis develops. |
| Malunion (deformity causing symptoms) | Varies by fracture type and definition | Non-surgical: Activity modification, orthotics, shoe wear modification, physical therapy for pain management.
Surgical: Corrective osteotomy (e.g., fibular, tibial), joint preservation procedures (e.g., arthroscopy for impingement), or ultimately arthrodesis/arthroplasty if severe arthrosis develops. |

| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and patient factors) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |

| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and patient factors) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |

| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |

| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction. |
| Nonunion (Failure of bony union) | 5-15% (varies by fracture type and definition) | Conservative: For stable, asymptomatic nonunions, especially with minimal functional impact.
Surgical: Excision of fibrous tissue, debridement of nonunion site, rigid internal fixation (e.g., locking plates), +/- bone grafting (autograft or allograft), osteotomy for malunion correction.