Ankle Fracture Management

Initial Assessment and Stabilization

• The American College of Radiology recommends immediate treatment for ankle fractures, including stabilization of the extremity in the position found, assessment of neurovascular status, application of the PRICE protocol, and appropriate imaging based on Ottawa Ankle Rules to guide further management 1
• The Ottawa Ankle Rules should be applied to determine the need for imaging, including radiographs if the patient has inability to bear weight immediately after injury, point tenderness over specific areas, or inability to ambulate for 4 steps in the emergency department 1
• Stabilize the extremity in the position found, check for vascular compromise by assessing pulses, capillary refill time, note temperature and color changes, and activate emergency medical services immediately if the extremity appears blue, purple, or pale, as recommended by the American Heart Association 2, 3
• Cover any open wounds with clean dressing to prevent contamination and infection, as suggested by the American Heart Association and the American College of Cardiology 3, 4
• Apply the PRICE protocol, which includes protection, rest, ice, compression, and elevation, for the initial management, with ice applied for 15-20 minutes every 2-3 hours for the first 48-72 hours, as recommended by the American Academy of Family Physicians and the American Heart Association 5, 3

Imaging and Diagnosis

• Standard radiographic views for ankle fractures include anteroposterior view, lateral view, mortise view, and should include the base of the fifth metatarsal in imaging 1
• The American College of Radiology recommends using the Ottawa Ankle Rules to guide imaging decisions, with a focus on identifying patients who require radiographs 1
• Radiographs are the initial imaging modality for suspected physeal injuries, as recommended by the American College of Radiology 6
• MRI is beneficial in assessing physeal injuries, especially in pediatric patients, as it is sensitive for diagnosing bone marrow contusion and evaluating the growth plate, according to the American College of Radiology 7
• Obtain standard three-view radiographs, including anteroposterior, lateral, and mortise views, with weight-bearing views if possible, and including the base of the fifth metatarsal in imaging, as recommended by the Journal of the American College of Radiology 1

Treatment and Management

• The American College of Radiology suggests that early surgery (within 24 hours) for unstable fractures reduces soft tissue complications and hospital stay, although the exact timing may depend on various factors 1
• Patients with specific characteristics, such as elderly patients (≥65 years), diabetic patients, and patients with peripheral vascular disease, may require more careful management and monitoring due to higher complication rates 1
• The American Academy of Orthopaedic Surgeons recommends that removable splints are the preferred method of immobilization for buckle fractures, resulting in better physical functioning and less difficulty with activities 2
• For proximal tibial buckle fractures, a removable knee immobilizer is preferable to a long leg cast, resulting in shorter immobilization time, fewer clinic visits, and fewer skin complications, with a strength of evidence not provided 2
• Closed reduction under appropriate anesthesia may be necessary, followed by immobilization if reduction is stable, as stated by the American Academy of Orthopaedic Surgeons 2
• Surgical fixation may be required if reduction cannot be maintained, there is intra-articular involvement, significant displacement, or an unstable fracture pattern, as recommended by the American Academy of Orthopaedic Surgeons 2
• Consider NSAIDs for pain and swelling management, though be aware they may potentially affect healing, with a strength of evidence not provided 4, 5
• Use alternative treatment approaches, such as non-removable casts or surgical fixation, for unstable ankle fractures, including those with medial clear space >4mm, bi- or trimalleolar fractures, fractures with significant displacement, open fractures, and high-energy fracture injuries, as recommended by the American College of Radiology 1

Rehabilitation and Follow-up

• Divide the rehabilitation process into three phases: early phase (1-2 weeks post-treatment), intermediate phase (2-6 weeks), and late phase (6+ weeks), with a focus on pain and swelling management, progressive weight-bearing, strengthening exercises, and proprioceptive training, as recommended by the American Heart Association 3
• Begin functional rehabilitation over prolonged immobilization, starting with range of motion exercises when safe, progressing to strengthening exercises, and including proprioceptive training to prevent recurrent injury, as recommended by the British Journal of Sports Medicine and the American Academy of Family Physicians 4, 5
• Use progressive weight-bearing as tolerated in a walking boot, with consideration of assistive devices to reduce weight-bearing on the affected limb, during the rehabilitation phase, as recommended by guidelines for managing diabetic foot complications 8
• Consider using ankle braces during high-risk activities to prevent recurrence, as suggested by the British Journal of Sports Medicine 4
• Perform proprioceptive exercises, such as ankle disk training, to prevent recurrent injury, as recommended by the American Academy of Family Physicians 5
• No routine fracture clinic follow-up is necessary for uncomplicated buckle fractures, as generally accepted by orthopedic specialists, with a strength of evidence not provided 2
• Provide clear instructions to parents/patients regarding duration of splint wear, when to seek medical attention, and expected timeline for return to normal activities, as recommended by orthopedic specialists, with a strength of evidence not provided 2
• Monitor diabetic patients carefully, as they have a higher complication risk (odds ratio 2.30), and consider comorbidities in the management, as noted by the American Diabetes Association 3
• Monitor patients with peripheral vascular disease carefully, as they have an increased complication risk (odds ratio 1.65), as part of the overall management plan, as recommended by the American Heart Association 3
• Physeal injuries have a higher risk of vascular injury and growth arrest, requiring thorough neurovascular assessment and close monitoring during healing and growth, as advised by the American College of Radiology 2