# Weightbearing assessment to guide nonoperative treatment of lateral malleolar fractures: the paradigm change

## TL;DR

This paper explains how to assess lateral ankle fractures to decide if surgery is needed, emphasizing the importance of weightbearing evaluation for non-surgical treatment.

## Contribution

The paper introduces the concept of 'congruent on weightbearing' to guide treatment decisions for lateral malleolar fractures.

## Key findings

- Lateral malleolar fractures with intact deltoid ligaments can maintain joint congruency under weightbearing.
- Fractures that remain congruent during weightbearing often heal without surgery.
- Early weightbearing and short immobilization improve recovery without increasing complications.

## Abstract

The goal of this Acta Orthopaedica educational article is to provide an update on how to evaluate lateral malleolar ankle fractures at the level of the syndesmosis and to guide clinicians in selecting the most appropriate treatment method. We aim to clarify the indications for non-surgical treatment and to provide clinicians with an evidence-based approach to decision-making in these frequently encountered injuries. The authors introduce the concept of “congruent on weightbearing” in contrast to the historical thinking of ankle fractures as stable or unstable. We further elaborate on how this thinking should be the basis in the decision-making regarding treatment method to safely differentiate fractures that will heal uneventfully without surgical intervention from those that need internal reduction and stabilization.

As long as crucial parts of the deltoid ligament are intact, lateral malleolar ankle fractures at the level of the syndesmosis maintain, or regain, joint congruency under weightbearing. Ankle fractures that stay congruent under weightbearing often heal uneventfully and can be safely treated without surgery. Furthermore, research has shown that early weightbearing and short immobilization periods are beneficial for patient recovery without an increase in complication rates.