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Fracture of ankle — Clinical Guidelines

Overview

Ankle fractures involve disruptions to the bones forming the ankle joint, commonly affecting the distal fibula, talus, or tibia, and can range from stable to complex dislocations. 2 6 12

Diagnosis

Key Diagnostic Criteria: Radiographic evaluation typically using anteroposterior, lateral, and mortise views to identify fractures accurately 10.

Recommended Tests: X-rays are essential; additional imaging like CT or MRI may be needed for complex fractures or to assess soft tissue injuries 2 10.

Grading Systems: Utilize classification systems such as Danis-Weber for syndesmotic injuries and Lauge-Hansen for mechanism-based classification, though exceptions exist 1 3.

Management

First-Line Treatments:

- Stable Fractures: Immobilization with functional braces may be as effective as plaster casts for recovery and functionality 5. - Unstable Fractures: Minimally invasive techniques like minimally invasive plate osteosynthesis are emerging alternatives to open reduction internal fixation, aiming to reduce wound complications 2.

Adjunctive Treatments:

- Pain Control: Intra-articular hematoma block or procedural sedation for closed reduction, with hematoma block showing comparable safety and efficacy 4 7. - Reduction Techniques: Prompt reduction using hematoma block for anesthesia in field settings or urgent care to restore neurovascular integrity 6.

Special Populations

Pediatrics: Clinical prediction rules can help identify significant fractures in children after twisting injuries, focusing on malleolar and midfoot zones 8.

Elderly: Older adults commonly sustain low-energy ankle fractures, emphasizing the need for careful assessment of comorbidities and functional outcomes 6.

Comorbidities: Consideration of associated injuries like Maisonneuve fractures involving the proximal fibula and triplane fractures is crucial for comprehensive treatment planning 9.

Key Recommendations

Utilize anteroposterior, lateral, and mortise views for accurate radiographic diagnosis of ankle fractures (Evidence: Strong 10).

For stable ankle fractures, functional bracing can be considered equivalent to plaster casting in terms of recovery and functionality (Evidence: Moderate 5).

Minimally invasive techniques should be considered as alternatives to open reduction internal fixation for unstable distal fibular fractures to minimize wound complications (Evidence: Moderate 2).

Intra-articular hematoma block is a safe and effective method for anesthesia during closed reduction of ankle fractures, offering comparable efficacy to procedural sedation (Evidence: Moderate 4 7).

Prompt reduction using appropriate anesthesia is critical in field settings to prevent neurovascular compromise, especially in cases of suspected complex injuries (Evidence: Expert opinion 6).

References

1 Akra GA, Das A, Kristensen V, Coren E, Wu C, Reed DJ et al.. Interobserver Agreement of Ankle Fracture Classification Among Emergency Physicians. Emergency medicine Australasia : EMA 2025. link 2 Luong K, Huchital MJ, Saleh AM, Subik M. Management of Distal Fibular Fractures With Minimally Invasive Technique: A Systematic Review. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 2021. link 3 Zhao J, He M, Fang Z. An Exceptional Avulsion Fracture Above the Medial Malleolus: A Retrospective Case Series. Journal of the American Podiatric Medical Association 2020. link 4 MacCormick LM, Baynard T, Williams BR, Vang S, Xi M, Lafferty P. Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures. Foot & ankle international 2018. link 5 Thackray AJ, Taylor J. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Immobilisation of stable ankle fractures: plaster cast or functional brace?. Emergency medicine journal : EMJ 2013. link 6 Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness & environmental medicine 2009. link 7 White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. A prospective randomized trial. The Journal of bone and joint surgery. American volume 2008. link 8 Dayan PS, Vitale M, Langsam DJ, Ruzal-Shapiro C, Novick MK, Kuppermann N et al.. Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2004. link 9 Healy WA, Starkweather KD, Meyer J, Teplitz GA. Triplane fracture associated with a proximal third fibula fracture. American journal of orthopedics (Belle Mead, N.J.) 1996. link 10 Vangsness CT, Carter V, Hunt T, Kerr R, Newton E. Radiographic diagnosis of ankle fractures: are three views necessary?. Foot & ankle international 1994. link 11 Marcinko DE, Field N. Fractured anterior calcaneal process. The Journal of foot surgery 1988. link 12 Bauer M, Johnell O, Redlund-Johnell I, Johnsson K. Ankle fractures. Foot & ankle 1987. link

Fracture of ankle