Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

open fracture

1st line – emergency surgery

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INITIAL
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open fracture
1st line – 

emergency surgery

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]

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, then administration of tetanus toxoid be included regardless of the wound pattern or type (i.e., tetanus-prone or not).[52] 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]

Plus – referral to vascular surgeon

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INITIAL
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open fracture
|
vascular compromise
Plus – 

referral to vascular surgeon

Treatment recommended for ALL patients in selected patient group

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]​​

closed fracture + dislocation

1st line – closed reduction + splint

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INITIAL
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closed fracture + dislocation
1st line – 

closed reduction + splint

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][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@6bd9bdd9[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@d2cb07a[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@87aadfb

2nd line – open reduction + fixation

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INITIAL
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closed fracture + dislocation
2nd line – 

open reduction + fixation

Required if closed reduction is not successful.

Plus – referral to vascular surgeon

Back
INITIAL
|
closed fracture + dislocation
|
vascular compromise
Plus – 

referral to vascular surgeon

Treatment recommended for ALL patients in selected patient group

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]

ACUTE

isolated lateral malleolar fracture

1st line – short-leg cast

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ACUTE
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isolated lateral malleolar fracture
|
nondisplaced/minimally displaced + no talar shift
1st line – 

short-leg cast

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 trial, a 3-week period of immobilization proved noninferior to traditional 6 weeks of cast immobilisation for patients with stable, isolated Weber B type (transsyndesmotic) fibula fractures in their population, mean age 45 years.[53]

1st line – short-leg cast or internal fixation

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ACUTE
|
isolated lateral malleolar fracture
|
nondisplaced/minimally displaced + talar shift
1st line – 

short-leg cast or internal fixation

A short-leg nonweight-bearing cast can be given for 6 weeks.

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.[19]

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

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]

1st line – short-leg cast or internal fixation

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ACUTE
|
isolated lateral malleolar fracture
|
displaced + reducible
1st line – 

short-leg cast or internal fixation

A short-leg nonweight-bearing cast can be given for 6 weeks.[54]

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.[19]

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

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]

1st line – internal fixation

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ACUTE
|
isolated lateral malleolar fracture
|
displaced + irreducible
1st line – 

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 or intramedullary fixation may be used.[35][56]

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]

isolated medial malleolar fracture

1st line – short-leg cast

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ACUTE
|
isolated medial malleolar fracture
|
nondisplaced/minimally displaced
1st line – 

short-leg cast

A short-leg nonweight-bearing cast can be given for 6 weeks.

1st line – internal fixation

Back
ACUTE
|
isolated medial malleolar fracture
|
displaced
1st line – 

internal fixation

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

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]

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]

bimalleolar/trimalleolar fracture

1st line – short-leg cast or internal fixation

Back
ACUTE
|
bimalleolar/trimalleolar fracture
|
nondisplaced with congruent ankle mortise
1st line – 

short-leg cast or internal fixation

A short-leg nonweight-bearing cast can be given for 6 weeks.

1st line – internal fixation

Back
ACUTE
|
bimalleolar/trimalleolar fracture
|
displaced
1st line – 

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.[19]

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

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]

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. 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]

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]

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][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@303aa468[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@32e53899[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@6ce25497

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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