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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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