Rockwood Adults CH64

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CHAPTER 64 • Ankle Fractures

Author’s Preferred Treatment of Ankle Fractures (Algorithms 64-1 and 64-2)

Ankle fracture

Bimalleolar or trimalleolar

Medial malleolus

Lateral malleolus

Suprasyndesmotic

Undisplaced minimally displaced

Posterior malleolus >25%

Undisplaced

Displaced

Displaced

Operative

Nonoperative

Operative

Operative

Nonoperative

Widened medial clear space Positive walking test or stress test

Proximal two- thirds of fibula

Distal third of fibula

Stable syndesmosis

Unstable syndesmosis

Operative

Stable

Unstable

Operative

Operative

Nonoperative

Nonoperative

Algorithm 64-1.  Authors’ preferred treatment of ankle fractures: nonoperative versus operative manage- ment. When deciding on surgery, the age and medical condition of the patient should be taken into con- sideration.

It should be remembered that many ankle fractures are treated nonoperatively. An algorithm to facilitate the deci- sion as to whether to operate on an ankle fracture is shown in Algorithm 64-1, and an algorithm for the treatment of surgically managed ankle fractures is shown in Algorithm 64-2. Patients with an apparently isolated lateral malleolar frac- ture and a congruent mortise on their initial radiographs are provided with a functional brace and allowed to mobilize full weightbearing regardless of the presence or absence of medial-sided bruising or swelling. They are reviewed at 1 and 6 weeks post injury with AP and lateral radiographs. Neither stress views nor MRI is used routinely. If any talar shift is revealed, the patient is advised to undergo opera- tive fixation of the fibula (but not the deltoid ligament).

Otherwise they are discharged to physical therapy rehabili- tation at 6 weeks. Undisplaced or minimally displaced isolated fractures of the medial malleolus are managed nonoperatively with 6 weeks in a functional brace with full weightbearing as tol- erated. Where there is significant displacement, or where the fracture enters the joint through the tibial plafond, we advo- cate reduction and fixation to avoid a displaced nonunion. Bimalleolar fractures are by definition unstable injuries and the vast majority should be treated by reduction and internal fixation. However entirely undisplaced fractures, particularly in the elderly or infirm, can be treated nonop- eratively with a cast or brace provided the patient is kept under close clinical and radiographic review until union has occurred.