Ankle Fracture in Emergency Medicine Treatment & Management

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

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.
Next

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[11] 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 (also see Splinting, Ankle)
    • 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.
Previous
Next

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.
Previous
Proceed to Medication
 
 
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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.