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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, ORTenderness at the posterior edge or tip of the lateral malleolus, ORInability to bear weight both immediately and in the ED for four steps, ORTenderness 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 viewsAnteroposterior (AP)Lateral: talar dome/distal tibia incongruity indicate instabilityMortise (15- to 25-degree internal rotation view): symmetry of mortise; space between the medial malleolus and talus should be ≤4 mmAdditional 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 bearing1 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 unstableStable = nonoperative (1)[A]Unstable = surgeryLateral 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 reductionDo 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 immobilizationNo 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 controversialSurgical emergency, best if repaired within 24 hours

SURGERY/OTHER PROCEDURES

  • Surgical optionsOpen reduction internal fixation (ORIF); preferred in athletes and unstable fracturesExternal 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 surgeryImmediately 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

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-raysIn 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.