Ankle Fracture Treatment & Management

Updated: Oct 26, 2016
  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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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.

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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 [19] 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.

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.

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  (also see Splinting, Ankle) 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. [20]

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.

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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.

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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 awake for the first 24-48 hours. Ice works through splints. [21, 22]

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).

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.

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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.

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Prevention

Encourage the patient to undergo rehabilitation to regain strength of the ankle joint.

Orthotics and proper shoe gear may help prevent future injury.

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