Ankle Fracture Management in the ED 

Updated: Jan 31, 2022
Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Practice Essentials

The ankle is composed of 2 joints: the true ankle joint and the subtalar joint. Ankle fractures refer to fractures of the distal tibia, distal fibula, talus, and calcaneus. The true ankle joint contains the tibia (medial wall), fibula (lateral wall), and talus (the floor upon which the tibia and fibula rest) and allows dorsiflexion and plantar flexion, or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward the ceiling via the true ankle joint.

The subtalar joint consists of the talus and the calcaneus. The subtalar joint allows the foot to be inverted or everted; that is, the sole of the foot can be made to face inward (inverted) or outward (everted) through the subtalar joint.

Ankle fractures are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and are treated surgically.[1]  All patients with ankle injury should be evaluated for extensive and serious trauma depending on the circumstances. Chronic medical conditions, such as diabetes, peripheral vascular disease, and metabolic bone disease, may affect examination findings and treatment plans.

During evaluation of ankle fracture, important components of care include mechanism of injury (eg, eversion, inversion, dorsiflexion, plantar flexion), associated injuries (eg, vascular, ligamentous, capsular), need for immobilization (eg, application of a splint), and need for referral to a specialist for further treatment or evaluation (eg, additional immobilization, surgery, rehabilitation). Patients with ankle injury must be evaluated for further trauma.

Because a patient with ankle fracture often presents with symptoms similar to those of an ankle sprain, a complete and thorough examination of the involved extremity is needed to avoid misdiagnosis and prevent unnecessary radiographs. Indicators suggesting fracture include gross deformity, swelling (especially perimalleolar), bony tenderness, discoloration, and ecchymosis. Inability to bear weight on the injured foot also suggests a fracture.

Multiple classification schemes are used to classify ankle fractures. Emergency medicine physicians usually label ankle fractures according to the number of fractures in the ankle (unimalleolar, bimalleolar, trimalleolar).[2]

Routinely obtaining radiographs following an ankle injury is not cost-effective, because fewer than 15% of affected patients have a fracture. Patients without fractures are identified reliably on physical examination.  Diagnostic guidelines for suspected ankle fracture are available from the American College of Radiology (ACR) Appropriateness Criteria.[3]  The Ottawa Ankle Rules have been developed to predict the necessity of radiographs in acute ankle injuries, with the goal of protecting patients from unnecessary radiation exposure.[4]

For an isolated ankle injury, confirm the neurovascular status of the concerned limb, manage pain, and prevent further damage.

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). Unless neurovascular compromise is noted, reduction is best deferred to the orthopedic consultant when an unstable ankle fracture is diagnosed.

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.

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).

Pathophysiology

The primary motion of the ankle at the true ankle joint (tibiotalar joint) consists of plantarflexion and dorsiflexion. Inversion and eversion occur at the subtalar joint.

Excessive inversion stress is the most common cause of ankle injuriy for 2 anatomic reasons. First, the medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert. Second, the deltoid ligament stabilizing the medial aspect of the ankle joint offers stronger support than is offered by the thinner lateral ligaments. As a result, the ankle is more stable and is more resistant to eversion injury than inversion injury. However, when eversion injury occurs, bony and ligamentous supporting structures undergo substantial damage, and loss of joint stability is noted.

Posterior malleolar fractures are usually associated with other fractures and/or with ligamentous disruption. They are commonly associated with fibular fractures and are often unstable.

Transverse malleolar fractures usually represent an avulsion-type injury. Vertical malleolar fractures result from talar impaction.

Epidemiology

Ankle fractures (AFs) are the most common fractures of the lower limbs found in emergency services. Approximately 53% of these fractures are unstable and are treated surgically.[1]

Nationwide epidemiologic data regarding ankle fractures are scarce. Such information is important toward better quantifying the mortality associated with such injuries, as well as the financial impact and the implementation of preventive measures. Findings show that an estimated total of 673,214 ankle fractures occurred during a 5-year period, with an incidence rate of 4.22/10,000 person-years. The mean age of patients with an ankle fracture was 37 ± 22.86 (SD) years; 23.5% of ankle fractures occurred in patients aged 10-19 years (7.56/10,000 person-years). In addition, 44% of ankle fractures occurred in men (3.81/10,000 person-years), whereas 56% occurred in women (4.63/10,000 person-years).[5]

Data on race/ethnicity were available for 71% of patients, with incidence rates of 2.85/10,000 person-years for whites, 3.01/10,000 person-years for blacks, and 4.08/10,000 person-years for others. The most common mechanism of injury was falls (54.83%), followed by sports (20.76%), exercise (16.84%), jumping (4.42%), trauma (2.84%), and other (0.30%).[5]

The highest incidence of ankle fracture in men occurred in the 10- to 19-year age group, but women were more commonly affected in all other age groups.[5]

Mortality/Morbidity

Patients with unrecognized or undertreated open ankle fracture are at high risk of infection, including local infection, osteomyelitis, and sepsis. Gas gangrene, the most serious infectious complication, can be both limb and life threatening.

Vascular supply to the ankle and foot may become compromised by development of a compartment syndrome or by direct injury to blood vessels from bone fragments.

Talar fractures, which commonly occur in snowboarding trauma, can cause osteoarthritis and subtalar joint degeneration.

Calcaneal fractures may compromise inversion and eversion of the ankle. Surgical complications and prolonged rehabilitation are common.

Older patients with ankle fracture experience more long-term complications than younger patients.

 

Pediatric ankle fractures are common and have unique fracture characteristics because of the presence of distal tibial and fibular physes. When displaced (>3 mm widening of the physis or >2 mm intra-articular gap/step-off), these fractures are typically treated with anatomic reduction internal fixation (ORIF). Computed tomography is recommended for preoperative evaluation and surgical planning for intra-articular fractures. These fractures in younger children, with substantial growth remaining, should be followed closely to monitor for any growth disturbance.[6]

Prognosis

The prognosis for ankle fracture can be improved with prompt, accurate diagnosis and appropriate treatment and referral. Complex open fractures with substantial soft tissue damage have a worse prognosis than isolated closed ankle fractures. Isolated, nondisplaced lateral malleolus fracture, the most common ankle fracture, has a favorable prognosis and heals unremarkably.

Aggressive rehabilitation helps reduce the majority of morbidity associated with ankle fracture. Limitations in functionality and physical capacity represent the main threats to health-related quality of life for patients with surgically treated AFs.[1]

Delayed access to care for patients with ankle fracture may increase the risk of complications, particularly if surgical management is warranted. An institutional retrospective study found that average time from injury to surgery was 8.3 days and 16.1 days for privately insured and Medicaid patients, respectively (P< 0.001). Patients enrolled in Medicaid have significantly delayed access to care compared to those with private insurance. For patients with ankle fracture, this is a critical healing time, and delayed care may result in increased costs, increased utilization of healthcare resources, higher complication rates, and poorer patient outcomes.[7]

 

Presentation

History

All patients with ankle injury should be evaluated for extensive and serious trauma, depending on the circumstances.

Details of the trauma, such as the direction of torque force applied to the ankle and the position of the foot, help predict the nature and severity of an ankle injury. Although patients tend to recall the event, they often cannot describe the exact manner in which the injury occurred.

History of prior trauma to the affected ankle may cause antecedent laxity, instability, or radiographic abnormalities misinterpreted as an acute event. Chronic medical conditions, such as diabetes, peripheral vascular disease, and metabolic bone disease, may affect examination findings and treatment plans. Long-term medication use is an important part of the history and has implications for management. For example, long-term use of corticosteroids may provoke premature osteoporosis, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) may mitigate the degree of swelling normally expected with fracture.

Physical

Because a patient with ankle fracture often presents with symptoms similar to those of an ankle sprain, a complete and thorough examination of the involved extremity is needed to avoid misdiagnosis and prevent unnecessary radiographs. Indicators suggesting fracture include gross deformity, swelling (especially perimalleolar), bony tenderness, discoloration, and ecchymosis. Inability to bear weight on the injured foot also suggests a fracture. The prognosis for ankle fracture can be improved with prompt, accurate diagnosis and appropriate treatment and referral.

Corroborate any visible deformity by gently manipulating the affected area. Inspect carefully for the presence of open wounds close to the injured ankle.

Assess the neurovascular status of the foot and ankle. Compare these findings with the unaffected extremity. Check for the presence and quality of pulse of the posterior tibial artery. Use a handheld Doppler to document arterial patency. Check for the presence and quality of pulse of the dorsalis pedis artery. Note that the dorsalis pedis is congenitally absent in 10-15% of the population. Document the time needed for capillary refill.

Palpate for focal bony tenderness, especially along the medial and lateral malleoli and the posterior aspect of the joint. If possible, palpate the most tender area last.

Assess passive and active range of motion of the ankle joint, noting limitations. During the immediate acute phase, most patients' ankles are too tender for them to cooperate with stress testing of the joint.

Examine the ipsilateral knee and foot, particularly documenting the condition of the proximal fibula and the proximal fifth metatarsal.

Causes

Multiple classification schemes are used to classify ankle fractures. The Lauge-Hansen system categorizes ankle fractures based on the position of the foot and forces acting on it at the time of injury[8] ; the Danis-Weber system relies on the level of fibular fracture.[9]  Neither classification scheme has proved prognostic, so emergency medicine physicians usually label ankle fractures according to the number of fractures in the ankle (unimalleolar, bimalleolar, trimalleolar).[2]

Types of ankle fractures

Pilon fracture

A pilon fracture designates a fracture of the distal tibial metaphysis combined with disruption of the talar dome. An axial loading mechanism drives the talus into the tibial plafond (the distal articular surface of the tibia). A common method of trauma is a foot braced against a floorboard in an auto collision. Skiers coming to an unexpected sudden stop and victims of free fall from heights also may sustain pilon fractures. Pilon fractures account for 1-10% of all tibial fractures. 

Establish vascular and integument integrity. Pilon fractures are often open. Skin sloughing is not uncommon. Subsequent edema, fracture blisters, and skin necrosis from the original injury may convert closed fractures to open injuries.

Depending on the trauma, associated injuries include spinal compression fractures (especially of L1) and ipsilateral or contralateral fractures of the os calcis, tibial plateau, pelvis, or acetabulum.

As pilon fractures are often comminuted and open, significant long-term disability often results.

(A pilon fracture is shown in the radiograph below.)

Pilon fracture in a 35-year-old man who fell 20 ft 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.

Maisonneuve fracture

A Maisonneuve fracture is defined as a proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament. Maisonneuve fractures are associated with partial or complete disruption of the syndesmosis. Treatment of Maisonneuve fracture depends on the stability of the ankle mortise. This unstable ankle injury requires operative treatment.[2]

(A Maisonneuve fracture is shown in the radiograph below.)

Maisonneuve injury. Mortise view shows transverse 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).

Tillaux fracture

A Tillaux fracture describes a Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis caused by extreme eversion and lateral rotation of the ankle. Incidence is highest among adolescents, usually those aged 12-14 years, because the fracture occurs after the medial aspect of the epiphyseal plate of the tibia closes but before the lateral aspect arrests.

Distinguish a Tillaux fracture from a triplane fracture. A triplane fracture is a combination of a Salter-Harris type II and type III fracture and is more likely than a Tillaux fracture to require open reduction internal fixation.

(A Tillaux fracture and a triplane fracture are shown in the radiographs below.[10] )

An 11-year-old girl with juvenile Tillaux fracture An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.
A 13-year-old girl with triplane fracture. Anterop A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.

Pott fracture

Bimalleolar fractures, termed Pott fractures, involve at least 2 elements of the ankle ring. These fractures should be considered unstable and require urgent orthopedic attention.

Cotton fracture

A trimalleolar, or Cotton, fracture involves the medial, lateral, and posterior malleoli. These fractures are considered unstable and require urgent orthopedic attention.

Snowboarder's fracture

With the popularity of snowboarding in the late adolescent and young adult population, it is likely the emergency physician will come across a fracture of the lateral process of the talus, the so-called snowboarding ankle fracture.[11, 12]

A combination of dorsiflexion and inversion of the ankle produces the lateral talar fracture.

A high index of suspicion should accompany treatment of snowboarders who report lateral ankle pain with a normal-appearing ankle radiograph. Computed tomography imaging is often required to diagnose a talar fracture.

Hyperplantarflexion variant ankle fracture

The ankle fracture “spur sign” has been found to be highly associated with the hyperplantarflexion variant ankle fracture, as determined by assessment of injury radiographs. This fracture is composed of a posterior tibial tip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. The spur sign is a double cortical density at the inferomedial tibial metaphysis.[3]

Bosworth fracture-dislocation

In this rare type of ankle fracture-dislocation, the fibula is posteriorly dislocated. The posterior tibial border blocks fibula reduction. Operative treatment is required to reduce and fix the fibula in the incisura fibularis.[2]

 

DDx

 

Workup

Laboratory Studies

No laboratory studies are necessary for patients with isolated ankle fracture when caused by a plausible mechanism. However, repeated ankle fracture or fracture caused by simple, low-force trauma may require investigation for osteoporosis, Charcot-Marie-Tooth disease, arthritis, connective tissue disease, or peripheral vascular disease.

Imaging Studies

Routinely obtaining radiographs following an ankle injury is not cost-effective, because less than 15% of affected patients have a fracture. Patients without fracture are identified reliably on physical examination. Stress radiographs assess the ankle during stress testing; however, results of this test generally are not sought for immediate ED management. The Shetty test is a valid clinical screening tool that can help the emergency physician decide whether simple radiography is indicated for foot and ankle injuries. It is a simple, quick, and reproducible test.[13]

Indications for ankle radiographs for patients with acute ankle pain include pain in the ankle region plus one of the following[14] :

  • Bony tenderness at the distal 6 cm of the posterior edge of the medial malleolus

  • Bony tenderness at the distal 6 cm of the posterior edge of the lateral malleolus

  • Inability to bear weight both immediately and in the ED (defined as 4 steps)

Diagnostic guidelines for suspected ankle fracture are available in the American College of Radiology (ACR) Appropriateness Criteria.[15]

ACR Appropriateness Criteria for acute trauma to the ankle include the following[16] :

  • Use of 3-view (anteroposterior, lateral, and mortise) radiographic evaluation for patients meeting the criteria of the Ottawa Ankle Rules
  • Cross-sectional imaging as a tool for preoperative planning and as a problem-solving technique for patients with persistent symptoms in whom occult fracture is suspected

The Ottawa Ankle Rules have been developed to predict the necessity of radiographs for acute ankle injuries, with the goal of protecting patients from unnecessary radiation exposure.[4]  These rules provide practical guidelines for selecting patients for radiographic studies.[17, 18]

Application of the Ottawa Ankle Rules to patients younger than 18 years is controversial. Although some advocate that the rules can be applied to children old enough to talk and walk, others use the age of 5 or 6 as a cut-off.[19]

Confounding variables to the Ottawa rules are (1) underlying neurologic deficit affecting the lower limb(s), (2) altered mental status, and (3) multisystem trauma.

Radiography

Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral, and mortise views) of the ankle. In the mortise view, the foot is rotated approximately 15° internally, allowing better visualization of the ankle mortise. Check the radiograph for the headset sign (ie, tibia sits atop the talus, resembling a headpiece on a receiver). Normally, the space between the cradle and the handle should be equal. Lack of symmetry suggests injury.

The ankle joint usually adheres to the ring axiom (eg, a fracture in one part of the ring often is associated with a second injury). Always look for an associated medial malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is seen. A vertical fracture of the medial malleolus is associated with either a lateral malleolar fracture or rupture of the lateral ligaments.

Accessory ossicles frequently appear adjacent to the medial and lateral malleoli and may mimic fracture. Clinical correlation is important. Accessory ossicles demonstrate well-corticated margins, whereas fracture fragments exhibit less-defined borders.

Radiographic examination of the foot is not required for patients with an isolated ankle complaint. Although an occult fracture of the base of the fifth metatarsal may occur, this should be detected with an adequately performed ankle radiograph.[20]

Externally rotated lateral radiographic projections can provide surgeons with additional information regarding the presence, size, and displacement of posterior malleolar ankle fractures, according to one study. In this study, posterior malleolar fractures were accurately identified on 86.67% (26/30) of standard lateral radiographs and on 100% (30/30) of externally rotated lateral radiographs. In addition, surgeons described the fracture with greater precision and had greater interclass correlation coefficient values regarding sagittal plane displacement (0.977 vs 0.939) and percentage of involvement of the tibial plafond (0.972 vs 0.775) with an externally rotated lateral projection, as compared to a standard lateral projection.[21]

Other imaging tools

Computed tomography (CT) and magnetic resonance imaging (MRI) studies may be performed as part of outpatient management when imaging features documented by other modalities are equivocal.[22]

Advanced imaging is most useful for diagnosing talar dome and triplane fractures, for distinguishing pilon from trimalleolar fractures, and for differentiating an accessory ossicle from an avulsion fracture. Occasionally, these tests are used to assess the complexity of the fracture and associated ligamentous and intra-articular injuries.

A bone scan rarely is indicated emergently. It may be useful for diagnosing and localizing stress fractures, infections, and neoplastic lesions.

A study of patients who presented to an urban level 1 trauma center with acute ankle injuries found that the sensitivity of bedside ultrasonography for detecting foot and/or ankle fractures was 100% and that the specificity of the Ottawa Foot and Ankle Rules increased from 50% to 100% with the addition of ultrasonography. Negative predictive value was 100%, and positive predictive value was 100%.[23]

 

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, manage pain, and prevent further damage.

  • Cover open fractures with wet sterile gauze.

  • 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.

  • 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:

  • 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:

  • Displaced medial, lateral, or posterior malleolar fracture

  • Medial malleolar fracture with lateral ligament damage

  • Lateral malleolar fracture with deltoid ligament damage

  • Fibular fracture at or proximal to the tibiotalar joint line 

  • 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. 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]

 

Guidelines

Guidelines Summary

Ottawa Ankle Rules for Ankle Injury Radiography

An ankle x-ray series is required only if there is any pain in the malleolar zone along with any of these findings[29] :

  • Bone tenderness at the posterior edge or tip of the lateral malleolus
  • Bone tenderness at the posterior edge or tip of the medial malleolus
  • Inability to take 4 complete steps both immediately and in the ED

A foot x-ray series is required only if there is any pain in the midfoot zone along with any of these findings:

  • Bone tenderness at the base of the fifth metatarsal
  • Bone tenderness at the navicular
  • Inability to take 4 complete steps both immediately and in the ED

Apply the Ottawa Ankle Rules accurately:

  • Palpate the entire distal 6 cm of the fibula and tibia.
  • Do not neglect the importance of medial malleolar tenderness.
  • Do not use for patients younger than 18 years.

Clinical judgment should prevail over these rules in the following circumstances:

  • Patient is intoxicated or uncooperative.
  • Patient has other distracting painful injuries.
  • Patient has diminished sensation in the legs.
  • Patient has gross swelling that prevents palpation of malleolar bone tenderness.

Give written instructions and encourage follow-up in 5-7 days if pain and ability to walk are not improved.

 

Medication

Medication Summary

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

Narcotic/analgesics

Class Summary

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

Morphine sulfate (Duramorph, Astramorph, MS Contin)

Used to achieve desired anxiolytic and analgesic effects 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 rapid onset and short duration (30-60 min). Easily titrated to desired level of pain control or sedation. Easily reversed by naloxone.

Anxiolytic/hypnotics

Class Summary

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

Class Summary

In procedural sedation, a benzodiazepine antagonist may be needed to reverse 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

Class Summary

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 fracture.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infection. Used in conjunction with gentamicin for prophylaxis in patients with open fracture.

Dose may need adjustment for patients with renal impairment.

Toxoids

Class Summary

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

Tetanus toxoid adsorbed or fluid

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 years; booster doses are needed throughout life to maintain tetanus immunity; pregnant patients should receive only tetanus toxoid—not a diphtheria antigen-containing product.

For children and adults, may be administered into deltoid or mid-lateral thigh muscles. For infants, preferred site is mid-thigh laterally.

Immunoglobulins

Class Summary

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

Tetanus immune globulin (TIG)

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