Prehospital Care
Patients with ankle injuries must be evaluated for further trauma.
For an isolated ankle injury, confirm neurovascular status of the concerned limb, manage pain, and prevent further damage.
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Cover open fractures with wet sterile gauze.
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Stabilize the suspected fracture site with a pillow splint, an air splint, or a bulky Jones dressing before transporting the patient. Try to immobilize the ankle in a neutral position if possible, but avoid excessive handling. Immobilization helps to decrease pain, bleeding, and damage to surrounding soft tissue.
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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, and any lateral malleolar fracture with significant talar shift.
If the 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, an external fixator, or open reduction internal fixation (ORIF).
An open fracture should be guarded from further contamination by covering the wound with a wet, sterile dressing secured by loosely wrapped dry, sterile gauze. Confirm current tetanus immunization; administer 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 is noted, reduction is best deferred to the orthopedic consultant when an unstable ankle fracture is diagnosed.
Closed reduction is accomplished as follows:
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The orthopedic consultant typically reduces ankle fractures. Ankle dislocations are reduced easily, and physicians treating a new fracture should be skilled in its initial management; however, immediate reduction of a dislocation may not be required unless blood flow to the foot is compromised. Local anesthesia is provided with a hematoma block [24] 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. Applying a concurrent distracting force often assists reduction attempts.
Simple, uncomplicated lateral malleolar fractures usually can be splinted in the ED; timely orthopedic follow-up care should be arranged. Bimalleolar, trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible ORIF.
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 whether NSAIDs impair fracture and ligament healing is a topic of controversy.
Admission criteria include open fracture, unstable fracture requiring urgent operative stabilization, and the presence of or potential for neurovascular compromise (eg severely comminuted pilon fracture causing a compartment syndrome).
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..
Stable injuries can be treated initially with a posterior splint. Ask the patient to lie prone with the knee bent to a 90º angle when a posterior splint is applied. 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 90º angle and mold the splint in the malleolar region.
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 the metatarsal heads. Secure in place with an elastic wrap. [25]
Splinting of a fracture with bulky padding (eg, Jones dressing) is indicated when immobilization and compression are needed but swelling is expected to progress. For 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:
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Displaced medial, lateral, or posterior malleolar fracture
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Medial malleolar fracture with lateral ligament damage
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Lateral malleolar fracture with deltoid ligament damage
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Fibular fracture at or proximal to the tibiotalar joint line
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All bimalleolar fractures
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All trimalleolar fractures
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All intra-articular fractures
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All open fractures
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All pilon fractures
Consult a vascular surgeon when vascular flow to the ankle or foot is compromised. For a fracture with vascular compromise, angiography may be necessary.
Medical 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 the patient is awake for the first 24-48 hours. Ice works through splints. [26, 27]
Advise patients to refrain from bearing weight on the ankle until seen by an orthopedist. Provide crutches and instructions on their proper use, and ensure proper use of crutches before discharge from the ED.
All patients with ankle fracture 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 circumstances that caused the ankle fracture must be assessed for safe discharge to home. The ankle fracture might have 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).
Indications for transferring the patient with an ankle fracture include patient or consultant request for a transfer and inability of the treating facility to sufficiently treat the ankle fracture (eg, requirement for ORIF in facility without an operating room). Provide adequate stabilization prior to transport. Discuss with accepting physicians the type of immobilization needed. A simple "pillow"-type splint or a more complex sterile dressing and a combination posterior and stirrup splint may be optimal. Be sure to document the neurovascular status of the leg and foot before and after immobilization.
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 in 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 is the likelihood of posttraumatic arthritis; comminuted pilon fractures are at greatest risk. Older patients have increased risk of arthritic complications.
Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle fracture. 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 fracture 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 fracture involving the growth plate may cause chronic deformity with disturbance of growth of the limb.
To inform healthcare professionals about what is important to patients when organizing an individualized, high-quality treatment plan, patient perspectives on treatment, care, and early rehabilitation are highly relevant. Findings reported by a longitudinal interview study indicate that further research is needed to develop a more specific description of symptoms that patients with ankle fracture should expect as treatment progresses, with the goal of decreasing psychosocial concerns regarding mobility, autonomy, and working ability post fracture. [28]
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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).
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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.
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A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.
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An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.
