Treatment of Broken Ankle with a Walking Boot
A walking boot can be used for certain types of broken ankles, but it is not appropriate for all ankle fractures and should only be used after proper evaluation and radiographic confirmation of fracture stability.
Initial Assessment and Diagnosis
- First, any suspected ankle fracture should be evaluated using the Ottawa Ankle Rules (OAR) to determine if radiographs are necessary 1
- The OAR criteria include:
- Inability to bear weight immediately after injury or take 4 steps
- Point tenderness over the medial malleolus, lateral malleolus, talus, or calcaneus
- Standard radiographic views (anteroposterior, lateral, and mortise views) should be obtained if OAR criteria are positive 1
- Weight-bearing radiographs provide important information about fracture stability if the patient can safely perform them
Appropriate Use of Walking Boots for Ankle Fractures
Suitable for Walking Boot Treatment:
- Stable, non-displaced ankle fractures
- Avulsion fractures of the fifth metatarsal base 2
- Later stages of treatment after initial immobilization in a cast
- Post-operative rehabilitation phase of surgically treated ankle fractures 3
Not Suitable for Walking Boot Treatment:
- Unstable ankle fractures (medial clear space >4mm)
- Bi- or trimalleolar fractures
- Fractures with significant displacement
- Open fractures
- High-energy fracture injuries 1
- Active Charcot neuro-osteoarthropathy (requires non-removable knee-high device) 1
Benefits of Walking Boot Treatment
Walking boots (removable cast boots/walkers) offer several advantages:
- Faster functional recovery compared to traditional plaster casts 3
- Earlier return to normal activities and work (mean 31.5 days vs 39.2 days with casts) 2
- Adjustable to accommodate swelling
- Allows for wound inspection and hygiene
- Rocker bottom design facilitates walking while protecting the ankle 3
Potential Complications of Walking Boot Use
- Secondary site pain is common (67% of patients), typically affecting:
- Lower back
- Contralateral hip
- Ipsilateral knee 4
- Most secondary pain (84%) begins within first 2 weeks of boot wear 4
- One-third of patients may still have new or worsened secondary site pain 3 months after stopping boot use 4
- Risk of non-compliance with removable devices
Treatment Protocol
Initial Phase (0-2 weeks post-diagnosis):
- For stable fractures: Removable walking boot with appropriate padding
- For unstable fractures: Non-removable cast or surgical fixation first
Rehabilitation Phase:
- Progressive weight-bearing as tolerated in the walking boot
- Consider assistive devices to reduce weight-bearing on the affected limb 1
- Monitor for secondary site pain and address with appropriate interventions
Transition Phase:
- Gradual transition out of the boot (typically 4-6 weeks depending on fracture type)
- Progressive return to normal footwear and activities
Special Considerations
- Elderly Patients: Higher risk of complications including wound problems, infection, and fixation failure 5
- Diabetic Patients: May require more prolonged immobilization and careful monitoring for skin breakdown
- Frail Elderly: May benefit from surgical approaches that allow immediate mobilization rather than boot treatment 6
Conclusion
For stable ankle fractures, a walking boot provides effective immobilization while allowing faster recovery and return to function compared to traditional casts, but must only be used after proper radiographic confirmation of fracture stability.