What is the management for an ankle inversion fracture?

Management of Ankle Inversion Fracture

The management of an ankle inversion fracture should begin with proper diagnosis using the Ottawa Ankle Rules (OAR) to determine the need for radiography, followed by PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for initial treatment, and functional rehabilitation with semi-rigid bracing rather than immobilization. 1

Diagnosis

Initial Assessment

• Apply the Ottawa Ankle Rules to determine need for radiography:
  • Pain on the dorsal side of one or both malleoli
  • Palpation pain at the base of the 5th metatarsal bone
  • Palpation pain of the navicular bone
  • Inability to walk at least four steps 1

Imaging

• Radiographs are indicated when OAR criteria are met
  • Standard views: anteroposterior, lateral, and mortise views (including base of fifth metatarsal) 1
  • Sensitivity of 92-99% for detecting ankle fractures 1
  • Weight-bearing radiographs provide important information about fracture stability if possible 1
• CT or MRI are not routinely used as first-line imaging but may be considered for:
  • Complex fractures requiring surgical planning
  • Suspected occult injuries with persistent symptoms 1

Treatment

Acute Phase (0-72 hours)

• PRICE protocol:
  • Protection: Avoid weight-bearing if painful
  • Rest: Limit activity that causes pain
  • Ice: Apply for 20 minutes several times daily
  • Compression: Use elastic bandage to reduce swelling
  • Elevation: Keep ankle elevated above heart level 1
• Pain management:
  • NSAIDs (ibuprofen, naproxen) or acetaminophen for pain control
  • Limit analgesic therapy to 2-7 days post-trauma 2

Rehabilitation Phase (After acute phase)

• Semi-rigid bracing is superior to elastic bandages and should be the standard treatment 1, 2
• Early mobilization and functional rehabilitation are preferred over immobilization 1, 2
• Exercise therapy to improve:
  • Proprioception
  • Coordination
  • Muscle strength 2

Treatment Based on Injury Severity

1. Grade I (Mild): Minimal ligament stretching

   • Semi-rigid brace or ankle support
   • Weight-bearing as tolerated
   • Return to activity in 1-2 weeks

2. Grade II (Moderate): Partial ligament tear

   • Semi-rigid brace
   • Progressive weight-bearing
   • Return to activity in 2-4 weeks

3. Grade III (Severe): Complete ligament rupture

   • Semi-rigid brace or short-term immobilization
   • Progressive weight-bearing
   • Return to activity in 4-8 weeks 1

Special Considerations

Avulsion Fractures

• Often undetected on routine radiographs
• May require additional views (ATFL or CFL views)
• Outcomes of functional treatment for avulsion fractures may be inferior to those for ligament injuries 3

Prevention of Recurrent Injury

• Use of semi-rigid or lace-up ankle supports can decrease risk of recurrent ankle injury, especially in patients with history of previous sprains 1
• Proprioceptive training and ankle disk exercises may help prevent future injuries 1

Monitoring and Follow-up

• Re-examination 4-5 days post-injury when pain and swelling have improved can help confirm diagnosis 1
• Monitor for complications such as chronic pain, instability, or post-traumatic arthritis
• Consider referral for persistent symptoms beyond expected recovery time

Common Pitfalls

• Failing to apply Ottawa Ankle Rules correctly, leading to unnecessary radiographs
• Inadequate treatment leading to chronic problems (decreased range of motion, pain, joint instability)
• Overlooking fractures of the lateral process of the talus, which can present similarly to ankle sprains 4
• Prolonged immobilization, which can lead to stiffness and delayed recovery