What is the management plan for an ankle hyperflexion injury with potential fracture fragments at the medial malleolus?

From the Guidelines

The management plan for an ankle hyperflexion injury with potential fracture fragments at the medial malleolus should prioritize immediate immobilization and diagnostic imaging to determine the extent of the injury, with consideration for surgical intervention if fracture fragments are significantly displaced or articular, as suggested by the American College of Foot and Ankle Surgeons 1.

Initial Assessment and Management

The initial assessment should include a thorough history and physical examination, with focal pain on palpation and radiographic studies to confirm the diagnosis.

• Immobilization is crucial to prevent further displacement of fracture fragments, and a posterior splint or walking boot can be used for this purpose.
• Weight-bearing should be restricted, with patients using crutches and maintaining non-weight-bearing or touch-down weight-bearing status until clinical reassessment.
• Diagnostic imaging, including three-view ankle radiographs (anteroposterior, lateral, and mortise views), is essential to determine the extent of the injury.

Pain Management and Follow-up Care

Pain management typically includes NSAIDs such as ibuprofen or naproxen, combined with acetaminophen as needed.

• Ice should be applied for 15-20 minutes every 2-3 hours during the first 48-72 hours to reduce swelling.
• Elevation of the affected limb above heart level when resting helps minimize edema.
• Orthopedic consultation is necessary within 1-2 weeks for definitive treatment planning, which may involve continued conservative management for non-displaced fractures or surgical intervention for displaced fractures.

Definitive Treatment Planning

Surgery is the usual treatment for significantly displaced or articular fractures, as it allows for anatomical realignment of the fracture fragments, preventing post-traumatic arthritis and ensuring proper ankle biomechanics, as noted in the study by the American College of Foot and Ankle Surgeons 1.

• Simple immobilization is appropriate when fracture fragments are small, nonarticular, or minimally displaced.
• Surgical intervention typically involves open reduction and internal fixation with screws or plates to restore ankle joint congruity and stability.

From the Research

Management Plan for Ankle Hyperflexion Injury

The management plan for an ankle hyperflexion injury with potential fracture fragments at the medial malleolus involves several steps:

• Assessment of the injury: This includes evaluating the mechanism of injury, comorbidities, associated injuries, soft tissue status, and neurovascular status 2.
• Imaging studies: Plain radiographs and computed tomography (CT) scans may be used to evaluate the extent of the injury, including the presence of fracture fragments and medial malleolar fractures 2.
• Correlation with site of focal tenderness: It is recommended to correlate the findings with the site of focal tenderness to determine the best course of treatment.
• Consideration of MRI: If there is ongoing concern, a magnetic resonance imaging (MRI) scan may be performed to further evaluate the injury.

Treatment Options

Treatment options for ankle hyperflexion injuries with potential fracture fragments at the medial malleolus include:

• Non-operative management: This may involve the use of a splint or cast, with early weightbearing allowed when the ankle is stable 2.
• Operative management: This may include open reduction and internal fixation, intramedullary nailing, or external fixation 2.
• Fixation of the medial malleolus: The decision to fix the medial malleolus depends on the fracture pattern and the presence of medial talar displacement 3.
• Consideration of deltoid ligament rupture: If there is a rupture of the deltoid ligament, treatment may involve direct repair of the capsular and deltoid injuries, including suture anchors in the medial malleolus and imbrication of the superficial and deep deltoid fibers 4.

Factors to Consider

When managing an ankle hyperflexion injury with potential fracture fragments at the medial malleolus, several factors should be considered:

• Fracture pattern: The type and location of the fracture can influence the treatment plan 3.
• Medial malleolar width: A decreased medial malleolar width may be associated with an increased risk of postoperative medial malleolar fracture 5.
• Varus malalignment: Varus malalignment of the tibial component may be associated with an increased risk of postoperative medial malleolar fracture 5.
• Prophylactic screw fixation: Prophylactic screw fixation may be considered in patients with a medial malleolar width <10.3 mm or at risk of postoperative varus deformity 5.