Functional bracing is a safe and cost effective treatment for isolated Weber B fracture

BackgroundDespite the current recommendations that stable Weber B ankle fractures can be treated with functional bracing and weightbearing as tolerated, some reluctance exists among trauma surgeons to follow these recommendations. This paper reports on our institution’s experience in managing these injuries and compare it to the national guidelines.Patients and methodsThis is a retrospective cohort study. Consecutive patients with isolated Weber B fractures referred to the local outpatient clinic over the period of six months were included in the study. Radiographs and clinic letters were examined, the patients were interviewed via telephone to obtain outcome scores [Olerud and Molander score]. Method of immobilisation, weight-bearing status, radiological fracture union, clinical outcomes and complications were all assessed and analysed.ResultsOne hundred and twenty-three patients with isolated Weber B fractures were identified. This cohort of patients did not show clinical or radiographic evidence of instability, they were deemed stable and were initially treated non-operatively. Minimum follow-up period was six months. Sixty-two patients were treated in plaster and were non-weight bearing on the affected limb, while 61 were treated with functional bracing in a boot and were allowed early weight bearing. Three patients showed displacement requiring surgical fixation. All fractures progressed to union and patients were discharged irrespective of the method of immobilisation or weightbearing status during treatment. There was no statistically significant difference in the functional outcome measures between the two groups. The protocol of functional bracing and weightbearing was associated with fewer outpatient clinics and a reduced number of radiographs obtained in the clinic and fewer complications.ConclusionIsolated trans-syndesmotic Weber B ankle fractures, that are clinically and radiologically stable, can be safely treated with functional bracing in a boot and weightbearing as tolerated.     

Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review

BackgroundDeltoid ligament injuries are typically caused by supination-external rotation or pronation injury. Numerous ligament reconstruction techniques have been proposed; however, clear indications for operative repair have not yet been well established in the literature.MethodsWe reviewed primary research articles comparing ORIF treatment for ankle fracture with versus without deltoid ligament repair.ResultsFive studies were identified with a total of 281 patients. 137 patients underwent ORIF with deltoid repair, while 144 patients underwent ORIF without deltoid ligament repair. Clinical, radiographic, and functional outcomes, as well as complications were considered. The average follow-up was 31 months (range, 5–120).ConclusionsCurrent literature does not provide clear indication for repair of the deltoid ligament at the time of ankle fracture repair. There may be some advantages of adding deltoid ligament repair for patients with high fibular fractures or in patients with concomitant syndesmotic fixation.Level of clinical evidence: III.     

Paratrooper's Ankle Fracture: Posterior Malleolar Fracture

BackgroundWe assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes.MethodsFifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity.ResultsThe patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome.ConclusionsPosterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs.     

Weber B ankle fracture: an unnecessary fracture clinic burden

Fifty-three patients with ankle fractures presenting to a trauma clinic at a busy district general hospital were used for this study. All subjects sustained fibular fractures at the syndesmosis without demonstrable medial instability or mortice incongruity. All cases were collected consecutively. Radiographs and case notes were studied for each patient. All fractures were categorised as Weber B [Pratique de l'osteosynthese. Les fractures malleolaires (1949)] without medial malleolar fracture. Data collected included the number of radiographs taken per patient and clinic reviews until discharge. Duration of immobilisation was recorded as well as weight bearing status. None of the 53 fractures showed any change in position following serial radiology. No patient underwent manipulation or internal fixation of the fracture. For Weber B fractures there was an average of six radiographs and 4.3 clinic reviews until discharge. There was a median time of 5.7 weeks spent in plaster immobilisation for these fractures. We conclude that once the decision is made to treat Weber B fractures as stable injuries they do not require regular review and serial radiographs. They require only one initial radiograph. Significant reductions in the number of trauma clinic consultations can be achieved as well as a national cost saving in the order of half a million pounds for the X-rays alone.     

Operative costs associated with arthroscopic assisted open reduction and internal fixation of acute ankle fractures

BackgroundAnkle fractures are a common orthopedic injury that frequently involves associated cartilage lesions, soft tissue damage, and a significant inflammatory burden. Despite studies revealing intra-articular pathology in up to 79% of ankle fractures, only 1% of open reduction and internal fixation (ORIF) procedures undergo arthroscopic evaluation. The primary purpose of this study was to determine the cost effectiveness of ankle arthroscopy performed at time of ORIF for ankle fracture.MethodsAn IRB approved retrospective review of patients who sustained ankle fractures and underwent ORIF with and without concomitant arthroscopic surgery between 2015 and 2020 were investigated. Patient demographics, fracture characteristics, outcomes, and cost data were collected and analyzed.ResultsThere were 567 total ORIF and 28 ORIF and scope included for cost analysis purposes. Total surgical costs averaged $6,537.62 and $6,886.46 for the ORIF only and ORIF and scope procedures respectively. Total direct costs, including operating room time, for the same procedures were found to average $6,212.34 and $7,312.10 for the ORIF only and ORIF and scope procedures respectively. The cost difference between the ORIF only and with arthroscopy was not statistically significant (p = 0.1174). Twelve of the 28 arthroscopic patients (42.86%) had grade 3 or full thickness chondral lesions, and 11/28 (39.28%) arthroscopic patients were found to have grade 1–2 cartilage changes.ConclusionIn the acute treatment of ankle fractures, concurrent arthroscopic evaluation does not add a significant cost to the procedure and may result in improved short and long term benefits for the patient. With improved arthroscopic efficiency, the cost differential can be further reduced.LOEIV.     

Investigation of incidence of superficial peroneal nerve injury following ankle fracture

The aim of this study was to investigate the incidence of superficial peroneal nerve (SPN) injury following ankle fracture and to establish whether this differed between those treated by open reduction and internal fixation (ORIF) and those treated nonoperatively in a cast. Two hundred eighty patients who had been treated for an ankle fracture either surgically (ORIF group) or nonoperatively (cast group) were identified. Patients were invited for review, assessed using the AOFAS scoring system, and examined for any evidence of SPN injury. The surgical approach was documented and all fractures were classified according to the Weber classification. A total of 120 patients returned for review; 56 patients from the ORIF group and 64 patients from the cast group. The mean time from injury to review was 2 years (range, 12-36 months). Overall, 18 patients (15%) had a symptomatic SPN injury and these patients had a significantly lower AOFAS score. In the cast group, 9% of patients had painful symptoms from an SPN injury, compared to 21% of patients in the ORIF group (p < .05). No evidence of SPN injury was found in those who had a posterolateral approach to the ankle. Surgeons should be aware that the SPN is at risk during lateral approach to the fibula and that injury to this nerve can frequently be identified as a cause of chronic ankle pain.     

Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function –Clinical study and MRI evaluation

PurposeTo compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up.Patients and methodsOne hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36.ResultsNo tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups.ConclusionThree-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.     

Short term clinical and patient reported outcomes following Virtual Fracture Clinic management of fifth metatarsal fractures

IntroductionFracture clinics are experiencing increased referrals and decreased capacity. Virtual fracture clinics (VFC) are an efficient, safe, and cost-effective solution for specified injury presentations. There is currently a lack of evidence to support the use of a VFC model in the management of 5th metatarsal base fractures. This study aims to assess clinical outcomes and patient satisfaction with the management of 5th metatarsal base fractures in VFC. We hypothesise that it is both safe and cost effectiveness.MethodsPatients presenting to VFC at our major trauma centre with a 5th metatarsal base fracture, between January 2019 and December 2019, were included. Patient demographics, clinic appointments, complication and operative rates were analysed. Patients received standardised VFC treatment; walker boot/full weight bearing, rehabilitation information and instructions to contact VFC if symptoms of pain persist after 4 months. Minimum follow-up was one year; Manchester-Oxford Foot Questionnaires (MOXFQ) were distributed. A basic cost analysis was performed.Results126 patients met inclusion criteria. Mean age was 41.6 years (18–92). Average time from ED attendance to VFC review was 2 days (1 – 5). Fractures were classified according to the Lawrence and Botte Classification with 104 (82%) zone 1 fractures, 15 (12%) zone 2 fractures and 7 (6%) zone 3 fractures. At VFC, 125/126 were discharged. 12 patients (9.5%) arranged further follow-up after initial discharge; pain the reason in all cases. There was 1 non-union during the study period. Average MOXFQ score post 1 year was 0.4/64, with only 11 patients scoring more than 0. In total, 248 face-to-face clinic visits were saved.ConclusionOur experience demonstrates that the management of 5th metatarsal base fractures in the VFC setting, with a well-defined protocol, can prove safe, efficient, cost effective and yield good short term clinical outcomes.     

Functional outcome 3–6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation

BackgroundTo compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation.MethodsIn total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3–6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires.ResultsIn total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046).ConclusionsIn multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.     

Standardised virtual fracture clinic management of Achilles tendon ruptures is safe and reproducible

BackgroundTraditional fracture clinics are some of the busiest clinics in a hospital, often with significant patient waiting times and delays. The use of virtual fracture clinic (VFC) for the management of certain injuries to reduce the workload on the traditional fracture clinic, in addition to reducing costs is growing in popularity. The tendoachilles is the most frequently ruptured tendon in the body but despite this, management remains a keenly debated topic.MethodsAll adult patients referred to the VFC with an actual or suspected Achilles tendon rupture were identified between January 2015 to October 2017.ResultsThis study found that patient with and acute achilles tendon ruptures managed according to a standardised VFC protocol had a re-rupture rate of 3.82%.ConclusionsOne of the advantages of a VFC model that is standardised, initiated in the ED, is that it has no variation in outcome seen in our patient group.     

The Cedell method (cerclage wire and staple) leads to less reoperations than the AO method

Background and purpose — Fractures of the lateral malleolus often require open reduction and internal fixation (ORIF). Despite uneventful fracture healing, many patients will suffer from long-term detriments after ORIF, such as local tenderness that requires hardware removal. In Sweden, there are 2 major fixation methods, either the AO method (plate and screws) or the Cedell method (cerclage wire and staple). The purpose of this study was to establish whether there is a difference in extraction frequency between the 2 methods.

Patients and methods — We performed a retrospective comparative study of all isolated fractures through the lateral malleolus that were operated at Skåne University Hospital, Sweden, during the period January 2007 to December 2010. 347 patients fulfilled the inclusion criteria (dislocated Weber B isolated fractures of the lateral malleolus) and were categorized according to fixation method. The numbers of reoperations, with preceding indication, were established from the charts. The median follow-up time was 59 (38–86) months after the primary surgery.

Results — 22% of the 110 patients treated with the AO method underwent a reoperation, as compared to 8% of the 237 patients treated with the Cedell method (p < 0.001). The median time to extraction was 16 (4–55) months.

Interpretation — Less implant removal is needed with the Cedell method than with the conventional AO method. This favors the use of the Cedell method in uncomplicated Weber B lateral ankle fractures, provided that other clinical parameters are comparable.     

Use of a synthetic bone void filler to augment screws in osteopenic ankle fracture fixation

Introduction Sufficiently stable constructs may be difficult to obtain with ankle fractures in patients with severe osteopenic bone. Augmentation of the osteosynthesis with a new synthetic bone void filler may help to solve this problem, and it can improve the clinical outcome.Materials and methods A prospective, open-label study was performed in two surgical clinics in Norway. In 37 of 42 selected patients with Weber type B ankle fractures showing clinical and radiologic signs of osteopenic bone, at least one screw was found to be stripping during open reduction and internal fixation (ORIF). All the stripped screws were augmented with the bone void filler, and tightness was assessed clinically afterwards. All patients were followed up for 2 years. Successful healing of the fracture after 3 months and absence of radiographic movement of the augmented screws were assessed relative to the plate and the bone. Safety was assessed by recording adverse events and abnormal haematology findings.Results All 86 augmented screws were clinically tight after augmentation. After 3 months, all fractures healed, and 1 augmented and 1 non-augmented screw appeared to be radiographically loose. After 2 and 6 months, respectively, deep wound infections occurred in 2 patients (5%), necessitating antibiotic treatment, revision surgery and implant removal. After 2 years, all patients had resumed their normal daily activities, and none of the augmented screws showed signs of loosening.Conclusions Augmentation of bone screws with this new synthetic bone void filler was an effective means of gaining screw anchorage. Screw stabilisation with the new synthetic bone void filler proved to be safe and effective in the ORIF of ankle fractures in patients with osteopenic bone.     

Does fracture obliquity in Weber B fibula fractures correlate with mortise instability?

BackgroundThe diagnosis of instability in the apparent, isolated distal fibula fracture can be challenging and often necessitates stress radiography. Danis & Weber classified lateral malleolar fractures based on the level of the fracture in relation to the syndesmosis. While Weber B fractures occur at the level of the syndesmosis, some such injuries present with a long, oblique pattern extending well above the syndesmosis. Given the well-established literature demonstrating that fractures above the syndesmosis correlate with a higher level of concomitant syndesmotic and deltoid ligament injury, we hypothesize that increased fracture obliquity, length and height of Weber B fibula fractures similarly correlates with increased mortise instability.MethodsAll patients with isolated Weber B fibula fractures who underwent gravity stress radiography met inclusion criteria. Fracture height was measured on mortise radiographs as: (1) the distance from the distal tip of the fibula to fracture apex, (2) the distance to the fracture apex as measured on a line drawn perpendicular to a line parallel to the plafond, (3) an angle subtended by a line drawn parallel to the plafond and a line drawn to the fracture apex and (4) a ratio of the absolute length as compared to fibular width.Results51 patients were included in the study. The group of 39 patients with stable ankles had a mean medial clear space of 3.12 ± 0.65 mm (range, 1.5 mm to 4.0 mm). The group of 12 patients with unstable ankles had a mean medial clear space of 6.29 ± 3.11 mm (range, 4.1 mm to 14.0 mm). These groups showed no significant difference in fracture angle (p = 0.93), fracture height from plafond (p = 0.49), fracture height from tip of fibula (p = 0.42), and as a ratio of absolute length to fibular width (p = 0.85).ConclusionIncreased fracture obliquity, length and height of Weber B fibula fractures did not correlate with a higher incidence of mortise instability. Despite the lack of positive correlation, future studies should continue to investigate and identify radiographic parameters of distal fibula fractures that are most predictive of instability.     

抗滑钢板治疗老年B型踝关节骨折

目的 观察抗滑钢板治疗老年踝关节骨折的临床效果。方法 对36例分类属于Danis-Weber B型的老年踝关节骨折使用抗滑钢板技术进行切开复位内固定，对踝关节功能进行评分，同时观察一些并发症的情况，如伤口感染、骨折不愈合、内固定失败等.结果 临床观察获得满意的结果，踝关节评分优良率达到91.6％。结论 抗滑钢板比传统外侧钢板具有理论上的优势，对Danis—Weber B型骨折推荐使用。     

Ankle fractures: functional and lifestyle outcomes at 2 years

Background: Ankle fractures form a high proportion of the total number of fractures treated in New Zealand. International studies show that there are mixed functional outcomes with differing fracture types and subsequently differing lifestyle outcomes. Methods: Fracture clinic records and orthopaedic admissions books for Wellington Public Hospital, Capital Coast Health, ­Wellington, were retrospectively reviewed to gain a population of patients who sustained ankle fractures for the period January?­December 1998. These patients were asked to fill in postal questionnaires detailing their current ankle function and lifestyle, two years after fracturing their ankle. The patients’ radiographs were reviewed to classify the types of ankle fractures sustained. Results: Of 141 patients that sustained ankle fractures, 74 were followed up 2 years after their ankle fracture. All fracture types averaged Olerud‐Molander ankle scores of 71.1. Weber A fractures averaged ankle function scores of 90, Weber B fractures 80, and Weber C fractures 78. Four patients (5%) achieved ‘poor’ results, 12 (16%) patients achieved a ‘fair’ result, 30 (41%) patients gained a ‘good’ result, 27 (36%) patients attained ‘excellent’ results. Lifestyle outcomes were reflected in the patient’s ankle function outcomes (P < 0.05). Conclusion: Patients who sustain ankle fractures can be expected to be still experiencing functional difficulties two years post‐treatment.     

Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study

Purpose

Long-term studies evaluating risk factors for development of ankle osteoarthritis (OA) following malleolar fractures are sparse.

Methods

We conducted a retrospective cohort study including consecutive patients treated by open reduction and internal fixation for malleolar fracture between January 1988 and December 1997. Perioperative information was obtained retrospectively. Patients were evaluated clinically and radiographically 12–22 years postoperatively. Radiographic ankle OA was determined on standardised radiographs using the Kellgren and Lawrence scale (grade 3–4 = advanced OA). Uni- and multivariate regression analyses were performed to determine risk factors for OA.

Results

During the inclusion period, 373 fractures (372 patients; 9% Weber A, 58% Weber B, 33% Weber C) were operated upon. The mean age at operation was 42.9 years. There were 102 patients seen at follow-up (mean follow-up 17.9 years). Those not available did not differ in demographics and fracture type from those seen. Advanced radiographic OA was present in 37 patients (36.3%). Significant risk factors were: Weber C fracture, associated medial malleolar fracture, fracture-dislocation, increasing body mass index, age 30 years or more and length of time since surgery.

Conclusions

Advanced radiographic OA was common 12–22 years after malleolar fracture. The probability of developing post-traumatic OA among patients having three or more risk factors was 60–70%.     

Distal tibiofibular synostosis after surgically resolved ankle fractures: An epidemiological,clinical and morphological evaluation of a patient sample

IntroductionAnkle fractures comprise a highly morphologically and etiologically diverse group of injuries, which includes various degrees of impairment of bone and ligamentous structures. The complete synostosis and incomplete bony bridging of tibiofibular syndesmosis are among the local late complications after surgically treated ankle fractures.Patients and method269 patients were evaluated, including 203 patients with Weber type-B fractures, and 66 patients with Weber type-C fractures. All patients underwent ankle radiography at standard intervals (post-operatively, 6 and 12 weeks, 6 and 12 months). The final assessment one year after osteosynthesis was performed. The study analyzed age, sex, fracture morphology, the location and morphology of ossification, functional outcomes and subjective evaluations of patient status.ResultsAs risk factors there were found male sex, tibiotalar dislocation, syndesmotic screw fixation and Weber type-C fractures. The severity of subjective difficulties and objective status were not dependent on the size of distal tibiofibular synostosis.Discussion and conclusionDespite relatively extensive imaging findings of complete synostosis or incomplete bony bridging, they only limited functional outcomes to a minimal extent.     

Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

Stable ankle joint fractures. Indications for operative or conservative treatment?

In German literature, ankle joint fractures are mostly classified in three groups according to Weber. In cases of the type A, the fracture line runs below, in cases of type B at height of the syndesmotic ligaments. C-type fractures are typically seen above this region. However, this practical and simple classification allows no inferences at accompanying injuries which in turn influence the functional outcome. We observed isolated fractures of the lateral malleolus in more than 60% of all type B-fractures, as soon as in the majority the type A-fractures. Since isolated medial ankle fractures occur very rarely, careful exclusion of further injuries is advisable here. In order to differentiate stable ones from unstable type B ankle injuries, we carry out a manual stress test, if there is less than 2 mm fracture dislocation and a congruent ankle mortise. In this manner we could find that stable lateral ankle fractures are characterized with a combination of an intact dorsal syndesmotic and medial ligament. Stable type B and undisplaced type A fractures were treated conservatively with an ankle brace (Aircast?). Unstable ankle injuries were treated by ORIF. Conservative treatment for undisplaced medial malleolar fractures is recommended, if x-rays showed less than 2 mm dislocation which allows a tibio-talare impingement. Biomechanical investigations could prove a significant increase in ankle joint stability, when an axial load of 300 N was applied to various horizontal loads. The talus does not follow automatically a displaced fibular fracture. The dorsal syndesmotic and the medial deltoid ligaments control ankle joint stability.     

Impact of intermittent pneumatic foot pumps on delay to surgery following ankle fracture

BackgroundAnkle fractures requiring open reduction and internal fixation (ORIF) are common and place considerable burden on inpatient beds. ORIF cannot be performed once the associated swelling is too excessive to permit tension-free wound closure. Where ORIF cannot be performed before the onset of swelling in the first 24–48 h, patients typically require up to 7 days of inpatient bed-rest and elevation to reduce swelling to an acceptable level for ORIF.The primary aim of this study was to determine whether delay to ORIF could be reduced with the pre-operative application of an intermittent pneumatic foot pump (IPF). These devices were designed as anti-embolic adjuncts, but have also been shown to be effective in the reduction of swelling.We compared 12 patients managed with an IPF to 12 matched historical controls who were not.No previous studies have addressed this question in unselected patients requiring ankle ORIF.MethodsWe performed a retrospective, controlled, before and after study of 24 patients who underwent ankle ORIF at our orthopaedic unit. Foot pumps were applied in the Accident and Emergency Department to ankle fracture patients requiring admission, and kept in place until ORIF.Data was collected from patient case notes for all patients.Patients were matched for age, gender, American Society of Anaesthesiologists (ASA) Grade, and pre-injury mobility. The primary outcome measure was time to surgery. We also recorded total hospital stay, and calculated cost savings.ResultsPatients managed with IPFs had a statistically significant 50% reduction in time from presentation to surgery compared to those managed without (p = 0.024), and had a reduced hospital stay (p = 0.116). This resulted in a net saving of £10,480 (£953 per patient).ConclusionsWe conclude that foot pumps reduce the time to surgery and total hospital stay of patients requiring ankle ORIF, and are cost effective.