eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Ankle: Follow-up

Author: Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital
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
Contributor Information and Disclosures

Updated: Feb 2, 2010

Follow-up

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)

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).

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.

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.

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.

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.

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.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to find fractures accounts for 20% of malpractice claims against emergency physicians. Causes include inadequate examinations, acceptance of inadequate films, lack of real-time radiology consultation, failure to promptly treat or consult when evidence of vascular compromise exists, failure to explain limits of initial radiographic interpretation, failure to immobilize and prevent further injury, and failure to arrange follow-up care.
  • Subtle fractures (eg, osteochondral lesions) may go undiagnosed because they are unrecognized on initial radiographs. When suspicion for a fracture remains high despite seemingly normal radiographs, splint the extremity, have the patient refrain from weight bearing, and arrange timely orthopedic referral.
  • Failure to provide clear and concise aftercare and follow-up instructions to all patients discharged from the ED is dangerous. Give details of splint or cast care and list symptoms that warrant immediate physician notification and/or return to the ED.
 
Acknowledgments

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



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References
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Further Reading

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Keywords

ankle fracture, broken ankle, ankle fracture treatment, ankle fracture symptoms, Maisonneuve fracture, medial malleolus fractures, open ankle fractures, pilon fracture, posterior malleolar fractures

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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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
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