How to manage feet swelling after a fracture?

Management of Feet Swelling After a Fracture

For post-fracture foot swelling, the combination of cryotherapy with exercise therapy is most effective for reducing swelling and improving function, while compression therapy alone or RICE (Rest, Ice, Compression, Elevation) alone has limited evidence supporting its effectiveness. 1

Initial Assessment and Management

• Weight-bearing radiographs should be obtained if possible to provide important information about fracture stability, with a medial clear space of <4 mm confirming stability 1
• Avoid manipulation of the ankle prior to radiographs in the absence of neurovascular deficit or critical skin injury to prevent complications 1
• If a fracture is associated with an open wound and severe bleeding, follow appropriate first aid for severe external bleeding 1
• If a fractured extremity appears blue, purple, or pale, seek immediate emergency medical attention as this indicates poor perfusion and a limb-threatening injury 1

Evidence-Based Swelling Management

Cryotherapy (Cold Application)

• Cold application can acutely decrease pain and swelling in joint injuries, though it does not improve function or time to recovery when used alone 1
• The greatest tissue cooling is achieved using a bag filled with ice and water surrounded by a damp cloth 1
• Limit cold application to 20-30 minutes, 3-4 times daily to prevent cold injury 1
• When combined with exercise therapy, cryotherapy has greater effect on reducing swelling compared to heat application and can significantly improve ankle function in the short term 1

Compression Therapy

• Compression wraps may provide comfort and relieve pain in the acute phase but have not been shown to reduce swelling or improve ankle function, range of motion, or time to recovery 1
• Multilayer compression therapy has shown better results in reducing ankle and hindfoot edema compared to standard treatment with ice 2
• Caution should be taken when applying compression to avoid compromising circulation from overtightening the wrap 1

Advanced Compression Options

• Arterio-venous foot pumps (AVFP) have been shown to reduce time to surgery and degree of swelling before operative intervention better than elevation alone 3
• The A-V Impulse "in-cast" system demonstrated significant benefit in managing ankle fractures that couldn't undergo immediate surgery, with reduced time for swelling to settle and fewer wound complications 4
• Multilayer compression therapy resulted in faster reduction of ankle and hindfoot edema compared to control groups using ice, though with slightly less ankle dorsiflexion on postoperative day three 2

Weight-Bearing Considerations

• In stable fractures, partial weight-bearing can be initiated with technical aids (walker or crutches) 5
• Progressive weight-bearing should be gradual, according to fracture stability and bone quality 5
• For fractures stabilized with hardware like Dynamic Compression Screws, full weight-bearing can usually be initiated between 6-8 weeks 5
• Progression to full weight-bearing should be based on radiological evidence of consolidation 5

Medication Considerations

• NSAIDs can be effective for reducing pain in the short term (<14 days) without significantly increasing adverse events compared to placebo 1
• For ankle injuries, oral or topical NSAIDs result in less pain in the short term 1
• Consider paracetamol (acetaminophen) as a regular analgesic, especially when avoiding NSAIDs 5

Important Caveats and Pitfalls

• RICE (Rest, Ice, Compression, Elevation) alone has no evidence supporting positive influence on pain, swelling, or patient function 1
• Intermittent impulse compression applied without additional compression by stockinette or bandage and without elevation in off-session periods is not superior to treatment with ice 2
• Avoid placing ice directly on the skin to prevent cold injury 1
• Monitor for signs of compartment syndrome, infection, malunion or nonunion as potential complications of foot fractures 6