Recommended approach: For this unstable fracture-dislocation pattern with deltoid injury, use a below-knee immobilisation device that protects the ankle in a plantigrade/neutral position for approximately 6 weeks, with the precise weight-bearing restriction and transition to mobilisation determined by the operating surgeon after confirming stable fibular, medial, and syndesmotic reduction. Carney 2022 Lenz 2022
A short period of rigid protection is appropriate initially, usually a well-padded below-knee plaster backslab/splint while swelling and the wound settle, followed by a below-knee cast or removable CAM/walker boot; a removable boot is preferable once the wound is secure because it permits controlled rehabilitation while maintaining protection. Carney 2022 Lenz 2022
Avoid prolonged rigid immobilisation beyond 6 weeks unless there is a specific surgical concern such as inadequate fixation, persisting instability, poor bone quality, neuropathy, or wound complications, because prolonged immobilisation can contribute to muscle atrophy, fibrosis, stiffness, and loss of function. NICE CKS
For a construct that includes stable dynamic syndesmotic fixation and reinforced ligamentous stabilisation, published postoperative protocols have used immediate protected weight-bearing in a CAM boot for 6 weeks, sagittal-plane range-of-motion exercises from 2 weeks, and progressive full range of motion and strengthening after week 6. Lenz 2022
However, this early-mobilisation pathway should not be extrapolated automatically to every fibular ORIF with ankle subluxation and deltoid disruption; the extent of syndesmotic injury, deltoid repair/reconstruction, fixation strength, reduction quality, soft-tissue status, and patient factors should determine whether weight bearing is deferred during the 6-week protection period. Femino 2022 Carney 2022
Practical pathway: Maintain splint/cast protection during the acute postoperative swelling phase, review the wound at approximately 2 weeks, then continue protection in a below-knee cast or CAM boot to a total of about 6 weeks. Carney 2022 Lenz 2022
- Use a neutral/plantigrade ankle position rather than plantarflexion when applying the splint, as changing a plantarflexed splint to neutral can markedly increase anterior ankle pressure. Farrar 2022 Walton 2022
- At 2 weeks, assess wound healing, neurovascular status, radiographic maintenance of mortise reduction, and evidence of syndesmotic or medial instability before allowing any ankle motion or loading progression. Lenz 2022 Raduan 2022
- From 2 to 6 weeks, permit only controlled sagittal ankle movement if fixation and ligament repair are judged secure; avoid inversion/eversion and rotational stress that may load the deltoid ligament and syndesmosis. Lenz 2022 Femino 2022
- After 6 weeks, begin progressive range-of-motion, calf strengthening, proprioception, and graded weight bearing once clinical and radiographic stability are confirmed. Lenz 2022 Carney 2022
Bottom line: A total of 6 weeks of below-knee protection, initially rigid and then preferably in a removable CAM boot when the wound permits, is a pragmatic stability-preserving regimen; incorporate earlier sagittal mobilisation only when the ORIF, syndesmosis, and deltoid construct are demonstrably secure. Carney 2022 Lenz 2022