From the Guidelines
Management of malleolar fractures in the emergency department begins with a thorough assessment including neurovascular status, soft tissue evaluation, and appropriate imaging, with radiographs indicated in patients who meet Ottawa Ankle Rules (OAR) criteria as the initial imaging study, as demonstrated by the study published in the Journal of the American College of Radiology in 2020 1.
Initial Assessment and Imaging
The initial assessment should include a thorough evaluation of the patient's neurovascular status, soft tissue, and appropriate imaging. Radiographs are indicated in patients who meet OAR criteria, with a sensitivity of 92-99% for detecting ankle fractures, as noted in the study by Smith et al 1. The typical radiographic protocol should include three standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity.
Management of Stable and Unstable Fractures
- Stable, non-displaced fractures can be managed with a posterior splint, non-weight bearing status, elevation, and ice to reduce swelling.
- Patients should receive adequate pain control with acetaminophen 1000mg every 6 hours and ibuprofen 400-600mg every 6-8 hours as first-line options, with oxycodone 5-10mg every 4-6 hours added for severe pain if needed.
- Unstable or displaced fractures require orthopedic consultation for potential surgical fixation, as emphasized by the guidelines for acute trauma to the ankle 1.
Discharge Instructions and Follow-up
- The splint should be applied with the ankle in neutral position at 90 degrees, and patients should be instructed to keep the extremity elevated above heart level when possible.
- Patients require clear discharge instructions including weight-bearing restrictions (typically non-weight bearing with crutches or walker), signs of compartment syndrome to watch for (increasing pain, paresthesias, pallor, paralysis, poikilothermia), and follow-up with orthopedics within 5-7 days, as recommended by the American Heart Association and American Red Cross guidelines for first aid in 2010 1. The most critical aspect of managing malleolar fractures is ensuring ankle stability, which is crucial for normal gait and function, and can be achieved by following the guidelines outlined above, as supported by the study published in the British Journal of Sports Medicine in 2012 1.
From the Research
Management of Malleolar Fractures in the Emergency Department
The management of malleolar fractures in the Emergency Department (ED) involves several key steps, including:
- Initial assessment and stabilization of the fracture with a splint, as well as careful evaluation of neurovascular status 2
- Reduction of the dislocation and splinting of the ankle under procedural sedation, if necessary 3
- Radiological imaging to confirm the diagnosis and assess the extent of the injury 3, 2
- Classification of the fracture according to the Lauge-Hansen or Weber classification to guide treatment decisions 4, 5
Treatment Options
Treatment options for malleolar fractures depend on the type and severity of the injury, and may include:
- Nonoperative treatment, such as conservative management with a splint or cast, for stable fractures 5
- Operative treatment, such as surgical repair with screws, plates, or tension-band wiring, for unstable fractures or those with significant displacement 4, 2, 5
- Specific considerations for certain types of fractures, such as isolated posterior malleolar fractures, which may require specialized imaging and treatment 6
Important Considerations
Important considerations in the management of malleolar fractures include:
- The potential for nerve or blood vessel damage, particularly in cases of fracture-dislocation 3
- The need for careful assessment of neurovascular status and monitoring for complications such as compartment syndrome 2
- The importance of accurate classification and interpretation of the fracture type to guide treatment decisions 4, 5