What is the treatment for an ankle fracture?

Ankle Fracture Management

The treatment for ankle fractures should follow a structured approach based on fracture stability, with stable fractures managed non-operatively and unstable fractures requiring surgical intervention. 1

Initial Assessment and Evaluation

• Apply the Ottawa Ankle Rules to determine need for imaging:

  • Pain in the malleolar zone
  • Bone tenderness at posterior edge of lateral or medial malleolus
  • Inability to bear weight for four steps immediately after injury 1

• Check for vascular compromise:

  • Assess pulses, capillary refill time
  • Note temperature and color changes in the foot
  • If extremity appears blue, purple, or pale, activate emergency response system immediately 2

• For suspected fractures, obtain standard three-view radiographs:

  • Anteroposterior view
  • Lateral view
  • Mortise view 1

Treatment Algorithm

1. Initial Management (All Ankle Fractures)

• Apply PRICE protocol:

  • Protection: Prevent further injury
  • Rest: Avoid activities that cause pain
  • Ice: Apply for 15-20 minutes every 2-3 hours for first 48-72 hours
  • Compression: Use bandage to control edema
  • Elevation: Keep ankle above heart level 1, 2

• Control pain with NSAIDs (note: may suppress natural healing process) 1

• Cover open wounds with clean dressing to prevent contamination and infection 2

2. Determine Fracture Stability

Stable Fractures (Non-displaced, isolated lateral malleolus)

• Non-operative management with splinting or casting
• Allow early weight-bearing as tolerated 1, 3

Unstable Fractures

Indicators of instability include:

• Medial clear space >4mm
• Bi- or trimalleolar fractures
• Significant displacement
• Open fractures
• High-energy injuries 1

3. Treatment Based on Stability

For Stable Fractures:

• Apply splint or cast
• Begin functional rehabilitation with early weight-bearing when appropriate 1
• Monitor for proper healing

For Unstable Fractures:

• Surgical intervention (open reduction and internal fixation)
• External fixation for severe soft tissue injuries
• Syndesmosis stabilization when indicated 1, 3

Important: Timing of surgery impacts outcomes. Early surgery (within 8 hours) for displaced fractures shows lower infection rates (3.0% vs 17.6%) and shorter hospital stays compared to delayed surgery 4

Special Considerations

• Diabetic patients: Higher complication risk (odds ratio 2.30); require careful monitoring 5
• Peripheral vascular disease: Increased complication risk (odds ratio 1.65) 5
• Open fractures: Five times higher risk of requiring future ankle fusion or replacement 5
• Trimalleolar fractures: Twice the risk of requiring future ankle fusion or replacement 5

Rehabilitation Protocol

1. Early Phase (1-2 weeks post-treatment):

   • Pain and swelling management
   • Gentle range of motion exercises when safe

2. Intermediate Phase (2-6 weeks):

   • Progressive weight-bearing as tolerated
   • Strengthening exercises
   • Consider assistive devices initially

3. Late Phase (6+ weeks):

   • Proprioceptive training to prevent recurrent injury
   • Return to normal activities gradually 1

Prevention of Recurrence

• Consider ankle braces during high-risk activities
• Perform proprioceptive exercises (ankle disk training)
• Focus on strengthening exercises 1

Caution: Functional outcomes are better in patients under 40 years and those receiving early surgical treatment for unstable fractures 6

The overall complication rate following proper treatment is low, with pulmonary embolism (0.34%), wound infection (1.44%), and revision surgery (0.82%) being uncommon 5.