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Ankle Fractures

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  • Ankle fractures are more common than sprains in children compared to adults because ligaments are stronger than physis.

  • Talar dome: osteochondral fracture of talar dome; suspect in child with nonhealing ankle "sprain"ť or recurrent effusions

  • Tillaux: isolated Salter-Harris III of distal tibia with growth plate involvement

  • Triplane fracture: Salter-Harris IV with fracture lines oriented in multiple planes: 2-, 3-, and 4-part variants

 

EPIDEMIOLOGY


  • Ankle fractures are responsible for 9% of all adult and 5% of all pediatric fractures
  • Peak incidence: females 45 to 64 years; males 8 to 15 years. Average is 46 years.

Incidence
  • 107 to 184 per 100,000 people per year
  • 3-fold increase in incidence predicted 2000 to 2030 in adults >60 years old

ETIOLOGY AND PATHOPHYSIOLOGY


  • Most common: falls (38%), inversion injury (32%), sports-related (10%)
  • Plantar flexion (joint less stable in this position)
  • Axial loading: tibial plafond or pilon fracture

RISK FACTORS


  • Age, fall, fracture history, polypharmacy, intoxication
  • Obesity, sedentary lifestyle
  • Sports, physical activity
  • History of smoking or diabetes
  • Alcohol or slippery surfaces

GENERAL PREVENTION


  • Nonslip, flat, protective shoes
  • Fall precautions in elderly

COMMONLY ASSOCIATED CONDITIONS


  • Most ankle fractures are isolated injuries, but 5% have associated fractures, usually in ipsilateral lower limb.
  • Ligamentous or cartilage injury (sprains)
  • Ankle or subtalar dislocation
  • Other axial loading or shearing injuries (i.e., vertebral compression or contralateral pelvic fractures)

DIAGNOSIS


HISTORY


  • Location of pain, timing, and mechanism of injury (key historical element is exact mechanism)
  • Weight-bearing status after injury
  • History of ankle injury or surgery
  • Tetanus status
  • Assess for safety and fall risk (especially in elderly).

PHYSICAL EXAM


  • Examine skin integrity (open vs. closed fracture).
  • Assess point of maximal tenderness.
  • Assess neurovascular status, pulses, motor/sensory exam, and ability to bear weight.
  • Evaluate for compartment syndrome.
  • Consider associated injuries (secondary survey).
  • Assess ankle stability: anterior drawer test for the anterior talofibular ligament (ATFL), talar tilt test for lateral and medial ligaments, squeeze test and external rotation stress test for the tibiofibular syndesmosis

DIFFERENTIAL DIAGNOSIS


  • Ankle sprain
  • Other fractures: talus, 5th metatarsal, calcaneus

DIAGNOSTIC TESTS & INTERPRETATION


  • Plain films: first line for suspected fractures (1)[A]
  • Ottawa Ankle Rules (OAR): Overall sensitivity of 98% in adults, increases to 99.6% if applied within the first 48 hours after trauma (2)[A].
  • OAR suggest films in patients aged 18 to 55 years if:
    • Tenderness at the posterior edge or tip of the medial malleolus, OR
    • Tenderness at the posterior edge or tip of the lateral malleolus, OR
    • Inability to bear weight both immediately and in the ED for four steps, OR
    • Tenderness at navicular or 5th metatarsal (Ottawa Foot Rules)
  • If symptoms persist past 48 to 72 hours, obtain x-rays.
  • In children >1 year old, OAR sensitivity is 98.5%.
  • OAR not valid for intoxicated patients, those with multiple injuries, or sensory deficits (neuropathy)
  • Three standard views
    • Anteroposterior (AP)
    • Lateral: talar dome/distal tibia incongruity indicate instability
    • Mortise (15- to 25-degree internal rotation view): symmetry of mortise; space between the medial malleolus and talus should be ≤4 mm
    • Additional stress view may demonstrate instability: increased medial clear space with manual external rotation

Pediatric Considerations

  • Consider tenderness over distal fibula with normal films as Salter-Harris I.

  • Stress views unnecessary in children and may cause physeal damage (3)[C].

  • Salter-Harris V often missed, diagnosed when leg length discrepancy or angular deformity after Salter-Harris I; rare, 1% of fractures (3)[C]

 
Follow-Up Tests & Special Considerations
  • CT recommended for operative planning in trimalleolar, Tillaux, triplane, pilon fractures, or fractures with intra-articular involvement (1)[A].
  • MRI not routinely indicated; does not increase sensitivity for detecting complex ankle fractures (4)[C]
    • MRI useful for chronic instability, osteochondral lesions, occult fractures, and unexpected stiffness in children

Diagnostic Procedures/Other
  • Ultrasound for soft tissue injury associated with displaced fractures (1)[A]
  • Bone scan or MRI for stress fracture

TREATMENT


GENERAL MEASURES


  • Immobilize in temporary cast/splint and protect with crutches/nonweight bearing
    • 1 to 2 weeks to allow decreased swelling, if not open or irreducible fracture (5)[C]
  • Ice and elevate the extremity; pain due to swelling best controlled with elevation (6)[A]
    • Compression stockings offer no benefit for swelling (7)[A].
  • Closed ankle fractures: stable versus unstable
    • Stable = nonoperative (1)[A]
    • Unstable = surgery
    • Lateral shift of talus ≥2 mm or displacement of either malleolus by 2 to 3 mm = surgery (5)[C]
    • In adults with displaced fractures: insufficient evidence if surgery or nonoperative management produces superior long-term outcomes (8)[A]
  • Stable syndesmosis injury = nonoperative
  • Fracture dislocations: urgent reduction
    • Do not wait for imaging if neurovascular compromise or obvious deformity.
    • Flex hip and knee 90 degrees for easier reduction.
    • Post reduction: neurovascular exam and x-rays

MEDICATION


First Line
  • NSAIDs and/or acetaminophen for pain (1)[A]
  • Initial IM pain injection (i.e., Ketorolac, ≥50 kg adult: 60 mg or 30 mg q6h, max 120 mg daily; children 2 to 16 years old, <50 kg or ≥ age 65 years: 1 mg/kg, 30 mg, or 15 mg q6h, max 60 mg daily) (6)[A]
  • For suspected open fractures: tetanus booster, broad-spectrum cephalosporin and aminoglycoside within 3 hours post injury (5)[C]
  • Intra-articular or hematoma block (1)[A]

Second Line
Opioid analgesics as adjunctive therapy (1)[A]  

ISSUES FOR REFERRAL


  • Consultation for neurovascular compromise, tenting of skin or open fracture, displaced or unstable fracture, compartment syndrome
  • All other fractures: follow-up within 1 week and remain nonweight bearing. Consult orthopedics if not comfortable with routine fracture management.

ADDITIONAL THERAPIES


  • Nonoperative = cast immobilization
    • No difference in type of immobilization (air-stirrup, cast, orthosis) (7)[A]
    • Initially nonweight bearing with crutches, then advance to 50% with crutches. Full weight bearing after 6 weeks post injury (6)[A]
    • If removable cast, gentle range of motion exercises at 4 weeks (6)[A]
  • Open ankle fractures (2%)
    • Remove gross debris/contamination in ED.
    • Duration of optimal antibiotic therapy controversial
    • Surgical emergency, best if repaired within 24 hours

SURGERY/OTHER PROCEDURES


  • Surgical options
    • Open reduction internal fixation (ORIF); preferred in athletes and unstable fractures
    • External fixation may be preferred in extreme tissue injury or comminuted fractures; may have more malunion compared to ORIF, but no difference in wound complications
  • Timing of surgery
    • Immediately if neurovascular compromise, open fracture, unsuccessful reduction, tissue necrosis (5)[C]
    • Otherwise delay >5 days post injury because inflammation can affect wound healing (5)[C].
  • Length of recovery: usually 6 to 8 weeks

Pediatric Considerations

  • Salter-Harris I and II = nonoperative

    • Distal tibia: long leg cast for 4 to 6 weeks, then short leg cast for 2 to 3 weeks (4)[C]

    • Distal fibula: posterior splint or ankle brace 3 to 4 weeks, weight bearing. If displaced, then short leg cast 4 to 6 weeks, nonweight bearing (4)[C]

    • Limit reduction attempts because of potential injury to growth plate (3,4)[C].

    • Reduction not recommended if presenting ≥1 week post injury (4)[C]

    • Intra-articular displacement of ≥2 mm in child with >2 years growth remaining = ORIF (3)[C]

  • Salter-Harris III and IV:

    • Distal tibia: if >2 mm displacement = ORIF (3)[C]

    • Distal fibula: rare, usually stable after tibial reduction (3)[C]

    • Tillaux and triplane: ORIF if displaced ≥2 mm (3,4)[C]

 
Geriatric Considerations

  • Higher surgical risk due to age/comorbidities

  • Osteoporosis increases risk of implant/fixation failure (8)[A].

  • Risks from surgery/anesthesia: wound healing problems, pulmonary embolism, mortality, amputation, reoperation

 

INPATIENT CONSIDERATIONS


Admission Criteria/Initial Stabilization
Admit if:  
  • Emergency surgery required
  • Patient nonadherent, lacks social support, unable to maintain non-weight-bearing status or has significant associated injuries
  • Concerning mechanism of injury (i.e., syncope, myocardial infarction, head injury)

Nursing
Nonweight bearing, maintain splint/cast, apply ice, keep leg elevated, pain control, assist in ADLs  
Discharge Criteria
  • Ambulates with walker or crutches
  • Medical workup (if needed) completed
  • Orthopedic follow-up arranged

ONGOING CARE


FOLLOW-UP RECOMMENDATIONS


Patient Monitoring
  • Orthopedic follow-up: serial x-rays
    • In children, sclerotic lines on x-ray (Parker-Harris growth arrest lines) indicate growth disturbance (4)[C].
  • Immobilize for 4 to 6 weeks, then progressive activity, weight bearing, with removable splint or boot (7)[A]
  • Physical therapy referral: no difference in outcomes between stretching, manual therapy, exercise program (7)[A]

DIET


NPO if surgery is being considered.  

PATIENT EDUCATION


  • Ice and elevate for 2 to 3 weeks, use crutches/cane as instructed, splint/cast care (avoid getting wet, etc.)
  • Notify physician if swelling increases, paresthesias, pain, or change in color of extremity

PROGNOSIS


  • Good results can be achieved without surgery if fracture is stable.
    • Most return to activity within 3 to 4 months
  • Most athletes return to preinjury activity levels.
  • Increasing age, NOT injury severity, associated with worsening mobility after fracture (9)[B]

COMPLICATIONS


  • Displaced fracture or instability
  • Delayed union, malunion, or nonunion (0.9-1.9%)
  • Postsurgical wound problems: loss of fixation, further surgery, amputation
  • Deep venous thrombosis
  • Complex regional pain syndrome, extensor retinaculum syndrome in children (4)[C]
  • Infection (osteomyelitis)
  • Posttraumatic arthritis, degenerative joint disease, growth arrest in children

REFERENCES


11 Ankle and foot disorders. In: Hegmann  KT, ed. Occupational Medicine Practice Guidelines. Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011:1-268. http://www.guideline.gov/content.aspx?id=36625&search=%22ankle+fractures%22. Accessed June 9, 2015.22 Polzer  H, Kanz  KG, Prall  WC, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia).  2012;4(1):e5.33 Kay  RM, Matthys  GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg.  2001;9(4):268-278.44 Parrino  A, Lee  MC. Ankle fractures in children. Curr Orthop Pract.  2013;24:617-624.55 Mandi  DM. Ankle fractures. Clin Podiatr Med Surg.  2012;29(2):155-186.66 Work Loss Data Institute. Ankle & Foot (Acute & Chronic). Encinitas, CA: Work Loss Data Institute; 2013. http://www.guideline.gov/content.aspx?id=47571&search=ankle+fracture. Accessed June 18, 2015.77 Lin  CW, Donker  NA, Refshauge  KM, et al. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev.  2012;(11):CD005595.88 Donken  CC, Al-Khateeb  H, Verhofstad  MH, et al. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev.  2012;(8):CD008470.99 Keene  D, James  G, Lamb  SE, et al. Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focusing on peripheral vessel function. Injury.  2013;44(7):987-993.

CODES


ICD10


  • S82.899A Oth fracture of unsp lower leg, init for clos fx
  • S82.899B Oth fracture of unsp lower leg, init for opn fx type I/2
  • S82.56XA Nondisp fx of medial malleolus of unsp tibia, init
  • S82.66XA Nondisp fx of lateral malleolus of unsp fibula, init
  • S82.892A Oth fracture of left lower leg, init for clos fx
  • S82.853B Displ trimalleol fx unsp lower leg, init for opn fx type I/2
  • S82.63XA Disp fx of lateral malleolus of unsp fibula, init
  • S82.891A Oth fracture of right lower leg, init for clos fx
  • S82.53XB Disp fx of med malleolus of unsp tibia, 7thB
  • S82.856B Nondisp trimalleol fx unsp low leg, init for opn fx type I/2
  • S82.66XB Nondisp fx of lateral malleolus of unsp fibula, 7thB
  • S82.856A Nondisplaced trimalleolar fracture of unsp lower leg, init
  • S82.843A Displaced bimalleolar fracture of unsp lower leg, init
  • S82.846B Nondisp bimalleol fx unsp low leg, init for opn fx type I/2
  • S82.63XB Disp fx of lateral malleolus of unsp fibula, 7thB
  • S82.56XB Nondisp fx of med malleolus of unsp tibia, 7thB
  • S82.843B Displ bimalleol fx unsp lower leg, init for opn fx type I/2
  • S82.309A Unsp fracture of lower end of unsp tibia, init for clos fx
  • S82.846A Nondisplaced bimalleolar fracture of unsp lower leg, init

ICD9


  • 824.8 Unspecified fracture of ankle, closed
  • 824.9 Unspecified fracture of ankle, open
  • 824.0 Fracture of medial malleolus, closed
  • 824.2 Fracture of lateral malleolus, closed
  • 824.6 Trimalleolar fracture, closed
  • 824.7 Trimalleolar fracture, open
  • 824.5 Bimalleolar fracture, open
  • 824.3 Fracture of lateral malleolus, open
  • 824.1 Fracture of medial malleolus, open
  • 824.4 Bimalleolar fracture, closed

SNOMED


  • 16114001 Fracture of ankle (disorder)
  • 48187004 Open fracture of ankle
  • 42188001 Closed fracture of ankle
  • 34268009 Closed fracture of lateral malleolus
  • 4673003 Open fracture of lateral malleolus
  • 10819981000119101 Open fracture of left ankle (disorder)
  • 10837541000119104 Open fracture of right ankle (disorder)
  • 54530004 Open fracture of medial malleolus
  • 6698000 Closed trimalleolar fracture
  • 25899002 Closed bimalleolar fracture
  • 10929641000119103 Closed fracture of right ankle (disorder)
  • 90338005 Open trimalleolar fracture
  • 15385006 Closed fracture of medial malleolus
  • 26908008 Open bimalleolar fracture
  • 10929681000119108 Closed fracture of left ankle (disorder)

CLINICAL PEARLS


  • OAR are nearly 100% sensitive in determining the need for x-rays.
  • Assess neurovascular status, ability to bear weight, associated injuries.
  • Assess joint above (Maisonneuve).
  • Normal x-rays with point tenderness indicate Salter-Harris type I fractures in children.
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