Ankle Fracture in Emergency Medicine Follow-up

  • Author: Kara Iskyan, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Feb 2, 2010
 

Further Inpatient Care

  • Admission criteria
    • Open fracture
    • Unstable fracture requiring urgent operative stabilization
    • Presence of or potential for neurovascular compromise (eg severely comminuted pilon fracture causing a compartment syndrome)
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Further Outpatient Care

  • Discharge instructions should include elevation of the affected leg, application of ice, and non-weight bearing on the injured joint.
  • Ice packs can be applied to areas of swelling for 10-15 minutes every 3-4 hours while awake for the first 24-48 hours. Ice works through splints.[12, 13]
  • Advise patients to refrain from bearing weight on the ankle until seen by orthopedist. Provide crutches and instructions on their proper use. Ensure proper use of the crutches before discharge from the ED.
  • All patients with ankle fractures should receive follow-up instructions for consultation with a specialist (eg orthopedist, podiatrist). Many fractures, with the exception of most unimalleolar fractures, will eventually require ORIF.
  • Patients with gait disorders or other reasons that caused the ankle fracture must be assessed for a safe discharge to home. The ankle fracture might have a low morbidity, but concomitant inability to attend to activities of daily living due to conditions, such as ataxia or peripheral neuropathy, may warrant mobilization of additional support services or admission.
  • Provide written and oral information on cast and/or splint care and ensure that the patient understands which symptoms warrant immediate physician notification and/or return to the ED.
  • With increased immobilization, patients are at higher risk for deep vein thrombosis (DVT).
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Inpatient & Outpatient Medications

  • Oral analgesics should be used liberally as long as they do not interfere with other medication or the patient's ability to ambulate. The emergency physician might consider prescribing a narcotic because controversy exists whether NSAIDs impair fracture and ligament healing.
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Transfer

  • Indications for transferring the patient with an ankle fracture include the patient's or consultant requests for a transfer and inability of the treating facility to sufficiently to treat the ankle fracture (eg, requirement for ORIF in facility without operating room).
  • Provide adequate stabilization prior to the transport.
  • Discuss the type of immobilization with the accepting physicians. It may be a simple "pillow" type splint or more complex sterile dressing and combination posterior and stirrup splint.
  • Be sure to document the neurovascular status of the leg and foot prior to and following the immobilization.
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Deterrence/Prevention

  • Encourage the patient to undergo rehabilitation to regain strength of the ankle joint.
  • Orthotics and proper shoe gear may help prevent future injury.
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Complications

  • Nonunion of the fracture site requires orthopedic referral for operative repair.
  • Malunion of the fracture site occurs more frequently than nonunion and potentially proceeds to degenerative changes of the joint. Chronic persistent symptoms such as pain, weakness, and instability of the ankle may develop. Refer such patients to an orthopedist for evaluation and possible surgical revision.
  • Traumatic arthritis complicates 20-40% of ankle fractures. Generally, the more severe the fracture, the greater the likelihood of posttraumatic arthritis; comminuted pilon fractures are most at risk. Older patients have an increased risk of arthritic complications.
  • Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle fractures. Clinical features include complex pain, muscle atrophy, cyanosis, and edema. The term Sudeck atrophy is reserved for RSD-like conditions accompanied by a characteristic radiographic appearance (ie, spotty rarefaction), as opposed to the ground-glass appearance seen with disuse atrophy of bone.
  • Osteochondral fractures of the talar surface can easily go unrecognized and if left untreated may result in chronic pain, locking, and swelling. If suspected, arrange appropriate orthopedic follow-up care.
  • In children, ankle fractures involving the growth plate may cause chronic deformity with disturbance of growth of the limb.
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Prognosis

  • The prognosis can be improved with prompt, accurate diagnosis and appropriate treatment and referral.
  • Complex open fractures with substantial soft-tissue damage have a worse prognosis than isolated closed ankle fractures.
  • Isolated, nondisplaced lateral malleolus fracture, the most common ankle fracture, has a favorable prognosis and heals unremarkably.
  • Aggressive rehabilitation helps reduce the majority of morbidity associated with ankle fractures.
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Patient Education

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Contributor Information and Disclosures
Author

Kara Iskyan, MD  Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital

Kara Iskyan, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Aronson, MD, FACEP  Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital, Ridley Park, Pennsylvania

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD  Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

David B Levy, DO, FACEP, FAAEM  Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. J Orthop Trauma. Jan 1998;12(1):67-8. [Medline].

  2. Shariff SS, Nathwani DK. Lauge-Hansen classification--a literature review. Injury. Sep 2006;37(9):888-90. [Medline].

  3. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. May 2007;21(5):307-15. [Medline].

  4. Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg. Mar-Apr 1996;35(2):127-33; discussion 189. [Medline].

  5. McCrory P, Bladin C. Fractures of the lateral process of the talus: a clinical review. "Snowboarder's ankle". Clin J Sport Med. Apr 1996;6(2):124-8. [Medline].

  6. Chan GM, Yoshida D. Fracture of the lateral process of the talus associated with snowboarding. Ann Emerg Med. Jun 2003;41(6):854-8. [Medline].

  7. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). Apr 2003;15(2):126-32. [Medline].

  8. [Guideline] Dalinka MK, Alazraki NP, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, et al. Suspected ankle fractures. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. [Full Text].

  9. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. Apr 2009;16(4):277-87. [Medline].

  10. Petscavage J, Baker SR, Clarkin K, Luk L. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. Oct 16 2009;[Medline].

  11. Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. J Orthop Trauma. Apr 1995;9(2):113-6. [Medline].

  12. Mora S, Zalavras CG, Wang L, et al. The role of pulsatile cold compression in edema resolution following ankle fractures: a randomized clinical trial. Foot Ankle Int. Nov 2002;23(11):999-1002. [Medline].

  13. Okcu G, Yercan HS. Is it possible to decrease skin temperature with ice packs under casts and bandages? A cross-sectional, randomized trial on normal and swollen ankles. Arch Orthop Trauma Surg. Dec 2006;126(10):668-73. [Medline].

  14. Birrer R, Cartwright T, Denton J. Immediate diagnosis of ankle trauma. In: The Physician and Sports Medicine. Vol 22. McGraw Hill; 1994:95-103.

  15. Bucholz RW, Heckman JD. Fractures in adults. In: Rockwood and Green's Fractures in Adults. 5th ed. 2001.

  16. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?. Acta Orthop Scand. Feb 1998;69(1):43-7. [Medline].

  17. Cummings RJ, Hahn GA. The incisural fracture. Foot Ankle Int. Mar 2004;25(3):132-5. [Medline].

  18. Daffner RH. Ankle trauma. Radiol Clin North Am. Mar 1990;28(2):395-421. [Medline].

  19. Derksen RJ, Bakker FC, Geervliet PC, et al. Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankleand foot rules by specialized emergency nurses. Am J Emerg Med. Oct 2005;23(6):725-9. [Medline].

  20. Duke Orthopaedics. Ankle Fractures. Wheeless' Textbook of Orthopaedics online. 2005:[Full Text].

  21. Fox A, Wykes P, Eccles K, et al. Five years of ankle fractures grouped by stability. Injury. Jul 2005;36(7):836-41. [Medline].

  22. Greenfield DM, Eastell R. Risk factors for ankle fracture. Osteoporos Int. 2001;12(2):97-103. [Medline].

  23. Holroyd BR, Wilson D, Rowe BH, et al. Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules. Am J Emerg Med. May 2004;22(3):149-55. [Medline].

  24. Kannus P, Palvanen M, Niemi S, et al. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone. Sep 2002;31(3):430-3. [Medline].

  25. Kirkpatrick DP, Hunter RE, Janes PC, et al. The snowboarder's foot and ankle. Am J Sports Med. Mar-Apr 1998;26(2):271-7. [Medline].

  26. Koury SI, Stone CK, Harrell G, et al. Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care. Feb 1999;15(1):37-9. [Medline].

  27. Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. Oct 2005;19(9):635-9. [Medline].

  28. Koval KJ, Zhou W, Sparks MJ, et al. Complications after ankle fracture in elderly patients. Foot Ankle Int. Dec 2007;28(12):1249-55. [Medline].

  29. Martin AG. Weber B ankle fracture: an unnecessary fracture clinic burden. Injury. Aug 2004;35(8):805-8. [Medline].

  30. Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR Imaging. Semin Musculoskelet Radiol. Sep 2005;9(3):210-26. [Medline].

  31. Nugent PJ. Ottawa Ankle Rules accurately asses injuries and reduce reliance on radiographs. J Fam Pract. Oct 2004;53(10):785-8. [Medline].

  32. Park JW, Kim SK, Hong JS, et al. Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma. Apr 2002;52(4):655-9. [Medline].

  33. Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury. Dec 2006;37(12):1157-65. [Medline].

  34. Ruiz E, Cicero J. Emergency Management of Skeletal Injuries. ed. Mosby-Year Book, Incorporated; 1995:517-541.

  35. Schmittenbecher PP. What must we respect in articular fractures in childhood?. Injury. Feb 2005;36 Suppl 1:A35-43. [Medline].

  36. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. Mar 16 1994;271(11):827-32. [Medline].

  37. Tang CW, Roidis N, Vaishnav S, et al. Position of the distal fibular fragment in pronation and supination ankle fractures: a CT evaluation. Foot Ankle Int. Jul 2003;24(7):561-6. [Medline].

  38. Thordarson DB. Detecting and treating common foot and ankle fractures: Part 1: The ankle and hindfoot. Phys Sportsmed. Sep 1996;24(9).

  39. Werner CM, Lorich DG, Gardner MJ, et al. Ankle fractures: it is not just a "simple" ankle fracture. Am J Orthop. Sep 2007;36(9):466-9. [Medline].

  40. Wexler RK. The injured ankle. Am Fam Physician. Feb 1 1998;57(3):474-80. [Medline].

 
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Maisonneuve injury. Mortise view shows transverse fracture of the medial malleolus and widening of the tibiofibular syndesmosis without a fracture of the fibula. This injury is suggestive of a proximal fibula fracture (Maisonneuve fracture).
Pilon fracture in a 35-year-old man who fell 20 ft. Anteroposterior radiograph shows at least 2 fracture lines extending to the articular surface (plafond) of the tibia.
A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.
An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.
 
 
 
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