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Ankle Fracture Follow-up

  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Dec 08, 2014
 

Further Outpatient Care

See the list below:

  • 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.[17, 18]
  • 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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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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Inpatient & Outpatient Medications

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  • 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

See the list below:

  • 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

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  • 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

See the list below:

  • 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

See the list below:

  • 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

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Broken Ankle (Ankle Fracture).

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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, 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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

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

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.

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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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