![]() ![]() When compared to healthy patients with an ankle fracture, diabetic patients have increased in-hospital mortality, postoperative complications, length of stay, and total hospital charges. Appropriate clinical management can reduce the possibility of severe disability or deformity. JOHNSON, ANDREW BRIAN THOMSON, in Levin and O'Neal's The Diabetic Foot (Seventh Edition), 2008 Management of Unstable Ankle Fractures in the Neuropathic PatientĪnkle fractures are encountered by a wide spectrum of providers. Truly isolated malleolar fractures in the absence of injury on the opposite side of the joint are stable fractures and do not lead to abnormal joint biomechanics. For a talar shift and consequent instability to develop, a ligamentous injury or fracture on both the medial and lateral sides of the ring must occur. If the ring has only one break, the ankle joint remains stable. The bones and ligaments of the ankle essentially form a ring around the joint ( Figure 13-3). Rather, knowledge of the typical patterns of ankle injury and the ligamentous injuries that accompany ankle fractures helps primary care providers accurately assess the stability of the ankle joint. 6,7 These classification schemes are complex and do not necessarily help the primary care provider distinguish stable from unstable fractures. The two most commonly used systems are the Lauge-Hansen and the Danis-Weber systems. In Fracture Management for Primary Care Updated Edition (Third Edition), 2018 ClassificationĪ number of classification systems exist for ankle fractures, which use the force applied and the position of the foot at the time of injury. Patients should be informed that the incidence of complex regional pain syndrome (CRPS) (see the section on “Complications”) after any injury in this area, including a fracture, is much higher when they smoke. If the patient smokes, the fracture healing time can be doubled it can also be delayed in patients who are taking antiinflammatory medications. When following an ankle fracture with radiographs, the mortise view should always be examined for evidence of new instability or a shift. Otherwise, medial and lateral malleolar fractures require a minimum of 4 weeks for clinical healing and possibly several months for radiographic healing. Unstable fractures (e.g., malleolar fracture with ligament disruption on the opposite side), displaced single malleolar, large (>25% of articular surface) or displaced (>2 mm) posterior malleolar, or trimalleolar (bilateral plus posterior malleolar) fractures (or if clinician is unsure about the stability of the fracture) should be referred. Isolated oblique lateral malleolar fractures at or below the ankle joint can be immobilized with a commercial walking fracture boot or short-leg walking cast for 4 to 6 weeks. A functional stirrup splint worn in a shoe may be adequate functional rehabilitation exercises can be started as soon as symptoms allow. Small, nondisplaced avulsion fractures are treated with early mobilization and weight bearing, as tolerated, similar to an ankle sprain. Small avulsion fractures, nondisplaced single malleolar fractures, and stable bimalleolar fractures can be treated nonoperatively. ![]() A nondisplaced fracture of the ankle is frequently seen in only one radiographic view of the ankle. There should be symmetric spacing throughout the mortise in other words, there should be less than 1 mm of displacement of the talus in any direction greater than elsewhere in the mortise. ![]() The ankle mortise is the joint space between the top of the talus and the bottom of the tibia, as well as the medial and lateral malleoli. If ankle radiographs are indicated, obtain lateral, AP, and mortise (AP view with the foot in 15 degrees of adduction) views. A first-degree ankle sprain will have tenderness only over the anterior talofibular ligament, whereas a second- or third-degree ankle sprain has tenderness over the talofibular and calcaneofibular ligaments. Point tenderness over the anterior and lateral ligaments (anterior talofibular and lateral calcaneofibular ligament) but not the fibula indicates an ankle sprain. This decision is supported by the Ottawa ankle rules, which indicate a radiograph is most predictive of fracture if the patient has pain over the malleolus and tenderness over the malleolus or the patient was unable to bear weight immediately at the time of injury and at the initial clinician visit. If no point tenderness is felt over the malleoli, then an x-ray is rarely necessary. The area of the posterior malleolus (distal tibia, immediately behind the medial malleolus) should also be palpated for tenderness. Point tenderness over the lateral malleolus (distal fibula) or medial malleolus (distal tibia) often indicates an ankle fracture as opposed to a sprain. Fowler MD, in Pfenninger and Fowler's Procedures for Primary Care, 2020 Ankle Fractures ![]()
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