Approach

Treatment is dependent on accurate determination of the nature and severity of the injury.

Conservative treatment is considered for nondisplaced fractures, anatomically reduced fractures (although functional outcome may be better if treated operatively), and patients with serious comorbidities who are not surgical candidates.[43]

Nonoperative management includes casting, either weight-bearing or nonweight-bearing, for a minimum of 6 weeks.[19][43]​ Functional management with controlled range of motion and combinations of nonweight-bearing or weight-bearing may also be considered.[44]​ UK guidelines recommend close contact casts as an alternative to surgery for patients over the age of 60 years, if reduction can be maintained with casts.[7][45]​ One randomized controlled trial of 620 adults over the age of 60 years with acute, overtly unstable ankle fracture found the use of close contact casting compared with surgery resulted in similar functional outcomes at 6 months, with fewer wound complications.[45]​ For conservatively treated fractures, it is important to gain serial radiographs to ensure the fracture has not been displaced again, joint congruity is maintained, and that it is healing appropriately. Repeat radiographs must be done immediately after reduction.[7][43]​ Some experts also suggest repeating radiographs at 5-7 days postreduction.[43]​ In fracture patterns where stability is uncertain, patients should be reviewed within 2 weeks with further radiographs (weight-bearing if possible) to confirm the position remains acceptable.[7]​ Operative treatment should be considered if the fracture displaces or fails to heal.[43]

A simple stability-based fracture classification can be useful in choosing between nonoperative and operative treatment because approximately one half of these fractures can be treated nonoperatively with success.[46]

For displaced or unstable fractures there is a 0.68-fold reduction in risk of an adverse event favoring operative compared with nonoperative management.[44]

Operative fixation techniques for ankle fractures are varied. There are no guidelines for fixation devices. Surgery on the soft tissue should be performed as soon as reasonably possible. A delay in operative treatment is associated with an increased rate of complications such as infection and lowered patient satisfaction.[47]

UK guidelines state that following surgery 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 or particular concerns about the status of the soft tissue in patients. All patients should be followed up in fracture clinic within 6 weeks of surgery to detect complications and confirm maintenance of reduction on radiographs.[7]

Analgesics

Pain should be assessed regularly using a pain assessment scale suitable for the person's age, developmental stage, and cognitive function.[42]​ In both the acute and aftercare settings, analgesics, including anti-inflammatory drugs, can be prescribed as necessary. There is no solid clinical evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit fracture healing. NSAIDs are effective for pain management in musculoskeletal trauma. Until there is clear evidence, their use should not be discouraged.[48]​ However, NSAIDs should not be offered to frail or older adults with fractures.[42]

Emergency treatment

Open fractures require emergency treatment, with a saline irrigation and debridement of the open wound and removal of all devitalized tissue, as well as foreign debris, by experienced surgeons.[49] The American Academy of Orthopaedic Surgeons (AAOS) recommends that patients with open fractures are brought to the operating room for debridement and irrigation as soon as possible, and ideally, within 24 hours postinjury.[39][40] Treatment of the fracture is then with internal fixation when the wound is determined to be clean.[39][40] In severely contaminated and comminuted fracture dislocations, temporizing external fixation may be required to facilitate repeated debridements, with delayed internal fixation.[39][40] Emergency fracture management includes splinting of the affected limb.[19]​ 

Timely transfer to specialists leads to better patient outcomes compared with acute surgery by inexperienced staff.[41]

Emergency treatment is also required in those with a fracture dislocation.[23]​ Radiographs should not be performed before reduction if they will cause an unacceptable delay.[7]​ Closed reduction is attempted with a short-leg splint or cast applied after successful reduction.[23]​ The choice of short-leg splint or cast is based on fracture type, patient factors, surgical urgency, and clinician preference.[23]​ If a successful closed reduction is not obtained, then open reduction and fixation is required on an urgent basis.

Emergency treatment is required in those with vascular compromise, with urgent referral to a vascular surgeon or plastic surgeon for consideration of arterial damage. In cases where there is neurovascular compromise, anatomic realignment should be attempted.[50]​ After reduction, the neurovascular status should be reassessed and documented. Adequate reduction should be confirmed by review of repeat radiographs.[7][43]

Antibiotics should be administered according to the type of open injury and severity of contamination at the time of diagnosis.[51] Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.​[39][40][49]​ Utilization of preoperative antibiotics is suggested to prevent surgical site infections in operative treatment of open fractures.[39][40] In patients with major extremity trauma undergoing surgery, the AAOS strongly recommends that antibiotic prophylaxis with systemic cefazolin or clindamycin be administered, except for type III (and possibly type II) open fractures, for which additional gram-negative coverage (e.g., piperacillin-tazobactam) is preferred.[39][40] The AAOS also states that in patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails, may be beneficial.[39][40] Recommended prophylactic regimens vary by region; therefore, local antibiotic protocols and advice from microbiology should be followed. Tetanus prophylaxis is administered depending on severity of injury and the tetanus status of the patient. Literature suggests that if tetanus immunization was more than 10 years prior, administration of tetanus toxoid should be included regardless of the wound pattern or type (i.e., tetanus-prone or not).[52][Figure caption and citation for the preceding image starts]: Backslab application: Webril is applied usually overlapping by about 50% to give at least 2 layers of padding under the plasterFrom the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@7cf42cec[Figure caption and citation for the preceding image starts]: Backslab application: the plaster slabs are then applied (2 side supports that wrap around the foot and one posterior support)From the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@49150c24[Figure caption and citation for the preceding image starts]: Backslab application: an optional layer of Webril over the plaster prevents the tensor bandage or flannel from sticking and allows for ease of removal. The tensor bandage is then applied (some use flannel wrap) with minimal to no tension; it is "just rolled on"From the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@5866efa9

The AAOS suggests wound coverage for fewer than 7 days from injury date.[39] After closed fracture fixation, negative pressure wound therapy may mitigate the risk of revision surgery or the use of surgical site infection surveillance protocol. However, after open fracture fixation, negative pressure wound therapy does not appear to offer an advantage when compared with sealed dressings, as it does not decrease wound complications or amputations.[39] Silver-coated dressings are not suggested to improve outcomes or decrease pin site infections.[39][40]

Isolated lateral malleolar fracture

If the fracture is nondisplaced, or very minimally displaced with congruent mortise and no talar shift visible on stress radiography, then a short-leg cast can be given for 6 weeks, with weight-bearing in the cast for the last 3 weeks. In one randomized, multicentre, noninferiority clinical trial, a shorter 3 week period of immobilization, either by cast or a simple orthosis, proved noninferior to traditional 6 weeks of cast immobilization for patients with stable, isolated Weber B type (transsyndesmotic) fibula fractures in their population, with a mean age of 45 years.[53] If there is talar shift, most patients will have open reduction and internal fixation; however, a short-leg nonweight-bearing cast for 6 weeks is still an option.

If the fracture is displaced and reducible, the options are either a short-leg nonweight-bearing cast for 6 weeks, or open reduction and internal fixation.[54]​ If the talar shift and lateral malleolus are not reducible, the only option is open reduction and internal fixation.[55]

One Cochrane review has shown that early treatment failure in nonoperatively treated patients led to surgery.[55]​​

Noncomminuted lateral malleolar fractures may be fixed with: 1) an interfragmentary lag screw and a neutralization plate; 2) posterior antiglide plate; 3) fibular intramedullary device.[19]

If the lateral malleolar fracture is comminuted, a bridge plate technique or intramedullary fixation may be used.[35][56]

Cost-utility analysis has shown that surgical treatment is not cost-effective compared with nonoperative treatment after 1 year. However, on a lifetime time horizon, assumed for a >3% reduction in lifetime incidence of ankle osteoarthritis with open reduction and internal fixation (ORIF), surgical treatment was found to be cost-effective.[57]

Isolated medial malleolar fracture

If the fracture is nondisplaced or very minimally displaced, then a short-leg cast can be given for 6 weeks. If the fracture is displaced, then operative management is indicated.

For medial malleolar fractures a buttress plate may be used for shearing fractures.[19]​ Transverse medial malleolar fractures may be fixed with 1 or 2 cancellous lag screws, tension band technique, or Kirschner wire fixation.[58]

Bimalleolar/trimalleolar fractures

If the fracture is completely nondisplaced with a congruent ankle mortise, the options are for either a short-leg nonweight-bearing cast for 6 weeks, or open reduction and internal fixation.

If the fracture is displaced, the only option is open reduction and internal fixation.[43]

Bimalleolar ankle fractures or fractures where there is talar shift or syndesmotic injury should be referred for specialist orthopedic care.

If the fracture of the medial malleolus is minimally displaced after operative fixation of the fibula, nonoperative treatment yields similar results compared with operative treatment in terms of pain, development of osteoarthritis, and patient-reported functional outcome after a mean of 39 months.[59]

Internal fixation

Operative fixation techniques for ankle fractures are varied. There are no guidelines for fixation devices.

Noncomminuted lateral malleolar fractures may be fixed with: 1) an interfragmentary lag screw and a neutralization plate; 2) posterior antiglide plate; 3) fibular intramedullary device.

If the lateral malleolar fracture is comminuted, a bridge plate technique may be used.

For medial malleolar fractures a buttress plate may be used for shearing fractures. Transverse medial malleolar fractures may be fixed with 1 or 2 cancellous lag screws, tension band technique, or Kirschner wire fixation.

After fixation of malleolar fractures, the syndesmosis should be tested for stability and, if unstable, fixation of the posterior malleolus or an anatomic reduction and stable fixation with syndesmotic screws are recommended.[35]

Fractures of the posterior malleolus are associated with higher-energy injuries and worse clinical outcomes.[34][60][61][62][63]​​

Posterior malleolar fractures may be fixed with a posteriorly applied buttress plate or compression screws.[60]​ The decision to treat posterior malleolar fractures and the indications for treatment are controversial.[34][60]​​​ Classic teaching suggests that fixation of the posterior malleolus be considered when the fracture size is greater than 25% to 33% of the joint surface.[61]​ However, one meta-analysis suggests that this is based on low-quality evidence and that there is no consensus in the literature regarding the appropriate fracture size for fixation. The authors reported fixation of the medial and lateral malleoli is more important for overall stability.[64]​ There has been a move towards fixation of more posterior malleolar fractures, as even with small areas of the articular surface, there can be significant disruption to the posterior components of the syndesmosis.[60][63]​ The decision to treat posterior malleolar fractures may also be determined by other factors such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation.[63]​ Computed tomographic (CT) imaging may be helpful in defining fracture comminution, size and configuration where fracture of the posterior malleolus is known or suspected.[7][33]​​[34][Figure caption and citation for the preceding image starts]: Mortise view of a trimalleolar fracture dislocation with concomitant disruption of the syndesmosisFrom the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@40c45484[Figure caption and citation for the preceding image starts]: Mortise view of a trimalleolar fracture after fixation. Note: 2 syndesmosis screws were also usedFrom the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@7be7dbe0[Figure caption and citation for the preceding image starts]: Lateral view of a trimalleolar fracture after fixationFrom the collection of B. Petrisor, MD; used with permission [Citation ends].com.bmj.content.model.Caption@4e768eaa

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