Ankle fractures are a common orthopedic problem. Assessing the instability of the ankle fragments helps guide management of the fracture. Not all fractures require surgery, but sometimes surgery is preferred to improve outcomes. Initial fracture care does require an attempt at restoring joint alignment. A reduction maneuver can be done along with the application of a splint or cast to hold the bones in a better position. The effectiveness of the reduction maneuver helps determine whether or not a patient requires surgery and how quickly the patient needs to go to the operating room for an external fixation device or open reduction internal fixation procedure. Patients usually use crutches to help keep weight off the injured ankle.
Casting
Casting is the definitive treatment for most fractures. The cast allows for strict immobilization of the injured bony structures. A cast can be pre-cut or bi-valved to allow for expansion to occur as the leg swells. Casts can be made of either fiberglass or plaster. A short leg cast is appropriate for most ankle fractures. A short leg cast goes from the toes to the lower part of the knee. The knee is not immobilized in a short leg cast. Casts can be applied as nonoperative care or after surgery to help immobilize the joint.
Splinting
According to Dr. Anne Boyd of the University of Pittsburgh School of Medicine, the splint has the advantage of allowing natural swelling to occur during the acute inflammatory phase after a fracture. A lower extremity splint can be applied to the foot and ankle for fractures. A "Bulky" Jones splint involves fluffy cotton or padding along with the rigid splint. The splint can be made of fiberglass or plaster. A posterior slab usually goes from the toes to the level of the knee but usually does not immobilize the knee joint. A U-shaped slab is applied to wrap around the sides of the ankle. Splints can be applied as either non-operative treatment or after a surgery to help immobilize the joint.
External Fixation
External fixation refers to the surgical application of a fixation device that remains outside the body. The surgeon places pins in the bones above and below the fracture site. A set of bars and clamps is then applied to the pins to help keep the bone fragments stable and in correct anatomic position. This can be part of the definitive treatment or part of a step-wise approach to fracture management. External fixation may be preferred in an acute setting and then converted to a fixation with internal hardware when swelling subsides. Occasionally, the bones remain unstable after internal fixation and the external fixation apparatus needs to stay in place.
Open Reduction Internal Fixation
Open reduction internal fixation refers to the surgical placement of screws, pins and plates under the skin to hold a fracture in place and stable. A surgeon may need to manipulate the bone fragments in the operating room to help get the best anatomic correction of the bones. Screws, pins and plates may remain in the bone forever or can be taken out at a later date.
Open Fracture Management
An open fracture is when the bony fragments of the fracture break the skin. Treatment of open fractures involves prompt surgical intervention to clean out the fracture site with large amounts of irrigation fluids. Patients may receive a tetanus vaccine. Antibiotic choice is dependent upon the size of the open wound and the level of contamination. The antibiotics that are prescribed include cefazolin, aminoglycosides and penicillin. Fractures are stabilized either with an external fixation device or with internal hardware in the operating room.
References
- "AAOS Comprehensive Orthopaedic Review"; Dr. Jay Lieberman, editor; 2008
- "Handbook of Fractures"; Dr. Kenneth Koval, Dr. Joseph Zuckerman, editors; 2006
- American Family Physician: Principles of Casting and Splinting
