Monitoring
Monitoring is dependent on the type of fracture as well as the management. Patients may undergo a period of rehabilitation and be reviewed both clinically and radiographically at 3 months following the initial injury for both non-operatively and operatively-treated fractures. This may be modified depending on clinical and radiographical examination; these are not strict guidelines.
One randomised controlled trial to determine the effectiveness of a supervised exercise programme and advice (rehabilitation) compared with advice alone after ankle fracture (either treated conservatively or operatively) showed similar outcome for the two groups. Therefore, a supervised exercise programme or physiotherapy is not routinely advised.[80][81]
Unimalleolar ankle fractures managed non-surgically: UK guidelines advise immediate, unrestricted weight-bearing as tolerated for patients with stable unilateral malleolar fractures.[44] Orthopaedic follow-up within 2 weeks is recommended if there is uncertainty about stability in unimalleolar ankle fractures that have been managed non-surgically.[7][44] Patients should return for review if symptoms are not improving 6 weeks after injury.[44]
Potentially unstable fractures treated non-operatively with cast application: it may be necessary to follow the patient weekly with serial x-rays to assess the position of the fracture, with cast removal at approximately 6 weeks depending on clinical and radiographic evidence of healing.[7]
Operatively-managed fractures: debate exists as to the most effective postoperative protocol following ankle fracture fixation.[44][82] Clinical review at 2 weeks to assess the surgical incisions is generally accepted. Patients should be followed up in a fracture clinic within 6 weeks of surgery to detect complications and confirm maintenance of reduction on radiographs.[7]
Traditional postoperative care after open reduction internal fixation of unstable ankle fractures with syndesmotic instability includes non-weight-bearing for 6 to 8 weeks.[83] Potential harms of early unrestricted weight-bearing may include wound infection or disruption of the healing site.[44]
However, immobilisation in a cast can result in stiffness of the ankle and non-weight-bearing can result in delayed functional recovery.[70][82] Therefore, UK guidelines state most patients should be allowed to bear weight as tolerated in a splint or cast unless there are specific concerns regarding the stability of the fixation or contraindications, such as peripheral neuropathy.[7] Possible benefits of early unrestricted weight-bearing are thought to include improved ambulatory function, quality of life, and an earlier return to work and sports.[44][70][82][84]
One systematic review suggests that there is no significant difference at 1 year in ankle motion or functional outcomes when comparing postoperative immobilisation and early range of motion. The review noted that early range of motion provided a quicker return to work; however, this was at the expense of an increased number of wound infections.[85]
Similarly, another systematic review, based on trials with significant heterogeneity, suggests that early range of motion and no immobilisation following surgery may provide a benefit to improved ankle range of motion, again at the expense of increased adverse events, which were mainly wound healing problems. The review also found, based on limited evidence, that manual therapy was not beneficial for ankle range of motion following surgical fixation.[86]
A multicentre randomised controlled trial of 110 patients compared early weight-bearing (after 2 weeks’ immobilisation) with late weight-bearing after operative fixation of unstable ankle fractures. Six weeks postoperatively, patients in the early weight-bearing group had significantly improved ankle range of motion (41 vs. 29 degrees), Olerud/Molander ankle function scores (45 vs. 32), and SF-36 scores on both the physical (51 vs. 42) and mental (66 vs. 54) components. These differences diminished at final follow-up after 12 months. There were no differences with regard to wound complications or infections and no cases of fixation failure or loss of reduction. Patients in the late weight-bearing group had higher rates of planned/performed hardware removal due to plate irritation (19% vs. 2%) at final follow-up after 12 months.[70]
A multicentre randomised controlled trial compared unprotected postoperative weight-bearing with protected weight-bearing and non-weight-bearing for 6 weeks in 115 patients with a Lauge-Hansen type supination external rotation (SER) 2-4 ankle fracture. The Olerud Molander Ankle Score (OMAS) was higher in the unprotected weight-bearing group after 6 weeks (61.2 ± 19.0) compared with the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (P=0.011). Unprotected weight-bearing showed a significant earlier return to work and sports and there were no differences in quality of life scores or the number of complications.[82]
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