Rockwood Adults CH64

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CHAPTER 64 • Ankle Fractures

A

B

C

D

Figure 64-25.  A, B: Hemorrhagic fracture blisters are unusual after a simple ankle fracture but represent a breach in the dermis. C, D: Consideration should be given to decompression of these blisters and allow- ing the region to re-epithelialize over a period of around 10 days before undertaking open reduction and internal fixation. In contrast, nonhemorrhagic blisters represent a shear injury with an intact dermis and are generally considered safe to operate through.

operation, a finding confirmed by others. 44,55,332 Both Scheper 332 and Mont et al. 260 have reported that a delay in surgery predicts a significantly poorer clinical outcome. Having ankle surgery as an inpatient has twice the risk of complications of ambula- tory day-case surgery, with greater costs. 341 Furthermore Fogel and Morrey 114 found increased difficulty in achieving an ana- tomical reduction and James et al. 165 found increased costs in patients treated with delayed fixation. If edema is a concern then methods to reduce the edema preoperatively have been proposed. Thordarson et al., 378 in an RCT, found a significant reduction in ankle edema when patients were managed with the use of a pneumatic pedal compression device in addition to the usual ice, elevation and immobilization, a finding con- firmed by Stöckle et al. 360 Mora et al., 263 in another RCT, found that a combined compression and cryotherapy device resulted in significant reduction in preoperative ankle swelling. The use of a fibular nail (see Fig. 64-23) may obviate many of these concerns by allowing percutaneous fracture fixa- tion with lower rates of wound complications. 20,411 Alterna- tively, in very low–demand patients with very compromised soft tissues, the use of a retrograde calcaneotalotibial nail

(Fig. 64-26) may provide immediate stability without the need for fracture exposure. 9,214 Tourniquet Use Tourniquets allow a bloodless surgical field, but a number of studies have described the potential disadvantages to their use. Konrad et al. 190 conducted an RCT comparing those operated on with and without the use of a tourniquet and reported a better range of motion and reduced postoperative pain and swelling in the patients treated without. Maffulli et al. 227 in another RCT found a significantly lower rate of wound complications and a more rapid return to work in patients managed without the use of a tourniquet although operating time was significantly longer. Thromboprophylaxis Lower limb trauma and joint immobilization are both known to predispose to venous thromboembolism (VTE). 132 Conser- vatively treated ankle fractures appear to be at very low risk, although emotive case reports tend to raise awareness of this rare problem. 58