eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Ankle: Treatment & Medication

Author: Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital
Coauthor(s): Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Jul 15, 2008

Treatment

Prehospital Care

  • Patients with ankle injuries must be evaluated for further trauma.
  • For an isolated ankle injury, confirm neurovascular status of the concerned limb, decrease pain, and prevent further damage. 
    • Cover open fractures with wet sterile gauze.
    • Stabilize the suspected fracture site with a pillow splint, air splint, or bulky Jones dressing before transporting patient. Try to immobilize the ankle in a neutral position if possible but avoid excessive handling. Immobilization helps decrease pain, bleeding, and damage to surrounding soft tissue.
    • Prehospital reduction of a fracture is not advised unless neurovascular compromise is evident (eg, presence of a cool, dusky foot) and a significantly prolonged transport time is anticipated.

Emergency Department Care

  • First, patients should be evaluated for multisystem trauma.
  • Once additional trauma is excluded, an ankle fracture should be identified as stable or unstable. Unstable fractures include any fracture-dislocation, any bimalleolar or trimalleolar fracture, or any lateral malleolar fracture with significant talar shift.
  • If neurovascular status of the extremity is compromised, the fracture should be reduced as soon as possible and reduction should be maintained during the healing period with a cast, external fixator, or open reduction and internal fixation (ORIF). 
  • Open fractures should be guarded from further contamination by covering wounds with a wet, sterile dressing secured by loosely wrapped dry sterile gauze. 
    • Confirm a current tetanus immunization, administering tetanus immunoglobulin when patients lack immunity and harbor a grossly contaminated wound.
    • Consider antibiotic prophylaxis, administering cefazolin for mild to moderately contaminated wounds and adding an aminoglycoside for highly contaminated wounds. Administer vancomycin and gentamicin if the patient is allergic to penicillin.
    • Leave fracture blisters intact. Once ruptured, blisters are more likely to become contaminated by skin flora.
  • Unless neurovascular compromise exists, reduction is best deferred to the orthopedic consultant when an unstable ankle fracture is diagnosed.
  • Closed reduction is accomplished as follows (refer to Dislocation, Ankle for specific techniques):
    • The orthopedic consultant typically reduces ankle fractures. Ankle dislocations are reduced easily, and physicians treating a new fracture should be skilled in their initial management; however, immediate reduction of a dislocation may not be required unless blood flow to the foot is compromised.
    • Provide either local anesthesia with a hematoma block or procedural sedation.
    • Closed reduction is best achieved by manipulating the limb to reverse the direction of the original deforming forces. For example, a fracture-dislocation resulting from abductive stress requires pushing the affected site in an adduct direction to restore. Applying a concurrent distracting force often assists reduction attempts.
  • Simple, uncomplicated lateral malleolar fractures usually can be splinted in the ED, followed by arrangement of timely orthopedic follow-up care. Bimalleolar, trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible ORIF.
  • Provide analgesics liberally.
  • Splinting and casting
    • Ankle splints are commercially available or may be constructed by sandwiching 10-12 layers of plaster between 4 sheets of cotton padding.
    • Posterior splint: Stable injuries can be treated initially with a posterior splint. Ask the patient to lie prone with the knee bent to a 90-degree angle when applying a posterior splint. Extend the splint from the metatarsal heads along the posterior surface of the leg to the level of the fibular head. Maintain the ankle at a 90-degree angle and mold the splint in the malleolar region.
    • Sugar tong/short leg stirrup splint: An alternative to the posterior splint is a sugar tong or short leg stirrup splint. Using 4- or 6-inch plaster, pass the splint under the plantar aspect of the foot, between the calcaneus and metatarsal heads. Secure in place with an elastic wrap.
    • Splinting of a fracture with bulky padding (eg, Jones dressing) is indicated when immobilization and compression are needed but swelling is expected to progress. In very unstable ankle fractures, apply a bivalve cast. A normal cast is bivalved by cutting completely through the casting material on the medial and lateral aspects longitudinally to avoid extremity compression. Next, the bivalved cast is overwrapped with an elastic bandage to stabilize the fracture site, while still allowing for swelling and expansion.

Consultations

  • Request orthopedic consultation for the following conditions:
    • Displaced medial, lateral, or posterior malleolar fracture
    • Medial malleolar fracture with lateral ligament damage
    • Lateral malleolar fracture with deltoid ligament damage
    • Fibula fracture at or proximal to the tibiotalar joint line (eg, Danis-Weber classification type C)
    • All bimalleolar fractures
    • All trimalleolar fractures
    • All intra-articular fractures
    • All open fractures
    • All pilon fractures
  • Consult a vascular surgeon when vascular flow to the ankle or foot is compromised. In a fracture with vascular compromise, angiography may be necessary.

Medication

Provide sufficient analgesia to patients sustaining an ankle fracture. A variety of medications can be used, ranging from oral acetaminophen to parenteral narcotics. For procedural sedation, agents include short-acting sedative-hypnotics and opiate analgesics, usually in combination. In addition, administer tetanus prophylaxis for open fractures.

Narcotic/analgesics

Pain control is essential to quality patient care. Ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Sedating properties of narcotics benefit patients who have sustained fractures.


Morphine sulfate (Duramorph, Astramorph, MS Contin)

Used to achieve a desired anxiolytic and analgesic effect because easily titrated to desired level of pain control or sedation. Reversed by naloxone.

Adult

2.5-5 mg IV q10-15min prn

Pediatric

Neonates: 0.05-0.2 mg/kg/dose IV prn
Children: 0.1-0.2 mg/kg q2-4h IV prn

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate


Fentanyl citrate (Duragesic, Sublimaze)

Good choice for immediate pain relief and conscious sedation because of its rapid onset and short duration (30-60 min). Easily titrated to desired level of pain control or sedation. Easily reversed by naloxone.

Adult

0.5-2 mcg/kg IV/IM; titrate to desired level of pain control and/or sedation in increments of 25-50 mcg IV

Pediatric

<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg IV/IM q60min
>12 years: Administer as in adults

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse effects

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation

Anxiolytic/hypnotics

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow administration of a smaller analgesic dose to achieve the same effect.


Midazolam hydrochloride (Versed)

Short-acting benzodiazepine/sedative hypnotic used for its anxiolytic, amnestic, and sedating properties. Easily titrated and easily reversed with flumazenil.

Adult

Loading dose: 0.05-0.1 mg/kg IV
Maintenance dose: 0.5-1 mg IV q3min prn; titrate to desired level of sedation

Pediatric

Infants <6 months: Not recommended
6 months to 5 years: 0.05-0.1 mg/kg IV; not to exceed total dose of 0.6 mg/kg
6-12 years: 0.025-0.05 mg/kg IV; not to exceed total dose of 0.4 mg/kg
>12 years: Administer as in adults

Sedative effects may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects due to decreased clearance

Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (diluent)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure

Antidotes

In procedural sedation, a benzodiazepine antagonist may be needed to reverse the sedation and respiratory depression resulting from benzodiazepines and narcotics.

An opioid antagonist also can be used to reverse oversedation in a patient manifesting significant respiratory depression.


Flumazenil (Romazicon)

Selective antagonist of benzodiazepine receptor.

Adult

0.2-0.3 mg IV q1min; total dose 2 mg once or 3 mg q1h

Pediatric

Not established
Recommended dose: Initially, 0.01 mg/kg IV over 15 sec, then 0.005-0.01 mg/kg IV q1min intervals; not to exceed 0.2 mg

Caution in cases of mixed drug overdose; toxic effects due to other drugs taken in overdose (eg, cyclic antidepressants) may occur with reversal of benzodiazepine effects

Documented hypersensitivity; serious cyclic-antidepressant overdosage; patients given a benzodiazepine for control of potentially life-threatening condition (eg, increased intracranial pressure or status epilepticus)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Patients on benzodiazepines for prolonged periods may experience seizures


Naloxone (Narcan)

Prevents or reverses opioid effects including hypotension, respiratory depression, and sedation, possibly by displacing opiates from their receptor. Rapid onset of 1-2 min. Oversedation or respiratory depression should reverse rapidly.

Adult

0.4-2 mg IV

Pediatric

0.01 mg/kg IV

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients addicted to opiates

Antibiotics

Therapy must cover all likely pathogens in the clinical setting.


Cefazolin (Ancef, Kefzol, Zolicef)

Cephalosporin that binds to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis, and inhibits bacterial replication. Primarily active against skin flora, including Staphylococcus aureus.
Total daily dosages are the same for IV and IM routes.

Adult

2 g IV/IM q6-12h; not to exceed 12 g/d

Pediatric

25-100 mg/kg/d IV/IM; not to exceed 6 g/d

Probenecid prolongs effect; aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test result for glucose

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy


Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Adult

1.5 mg/kg IV; not to exceed 80 mg

Pediatric

2 mg/kg IV

Other aminoglycosides, cephalosporins, penicillins, or amphotericin B may increase nephrotoxicity; enhances effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity—possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infections. Used in conjunction with gentamicin for prophylaxis in patients with open fractures.
May need to adjust dose in patients with renal impairment.

Adult

1 g IV over 1 h

Pediatric

Administer as in adults

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given over 2 h or by PO or IP route; red man syndrome not an allergic reaction

Toxoids

These agents are used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.


Tetanus toxoid

Used to induce active immunity against tetanus in selected patients; tetanus and diphtheria toxoids are immunizing agents of choice for most adults and children >7 y; administer booster doses throughout life to maintain tetanus immunity; pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site is midthigh laterally.

Adult

Primary immunization: 0.5 mL IM; 2 injections 4-8 wk apart; third dose 6-12 mo after second injection
Booster dose: 0.5 mL IM q10y

Pediatric

Administer as in adults

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons recommended

Immunoglobulins

Administer tetanus immune globulin to patients who may not have been immunized against Clostridium tetani products.


Tetanus immune globulins (Hyper-Tet)

For passive immunization of persons with wounds that may be contaminated with tetanus spores.

Adult

For prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid lesion
For clinical tetanus: 3,000-10,000 U IM

Pediatric

For prophylaxis: 250 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM

Because antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing, since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible

More on Fracture, Ankle

Overview: Fracture, Ankle
Differential Diagnoses & Workup: Fracture, Ankle
Treatment & Medication: Fracture, Ankle
Follow-up: Fracture, Ankle
References

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Further Reading

Keywords

ankle fracture, broken ankle, ankle joint, ankle injury, Maisonneuve fracture, medial malleolus fractures, open ankle fractures, pilon fracture, pediatric ankle fractures, posterior malleolar fractures, ankle pronation-external (eversion) rotation injuries, ankle supination, adduction injuries, ankle supination external (eversion) rotation injury, ankle syndesmotic injury, ankle trimalleolar fracture, vertical loading of the ankle, pronation dorsiflexion injury, ankle trauma

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, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency 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, 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: Nothing to disclose.

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, Medical Director, 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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