When to stress test an ankle fracture?

From the Guidelines

Stress ankle fractures should be imaged with radiographs as the initial imaging study, following the Ottawa Ankle Rules (OAR) criteria, as indicated by the American College of Radiology Appropriateness Criteria 1. When suspecting a stress fracture, excluding vertebrae, and radiographs are negative or indeterminate, the next imaging study should be considered based on the area of interest, which includes the ankle, as stated in the ACR Appropriateness Criteria 1. The decision to stress or image an ankle fracture depends on the clinical presentation and the presence of risk factors for fracture completion or the need for immediate diagnosis. Key considerations include:

• The use of radiographs as the initial imaging study, with a sensitivity of 92-99% for detecting ankle fractures 1
• The importance of weight-bearing radiographs in assessing fracture stability, particularly in cases of uncertain stability 1
• The role of other imaging modalities, such as MRI, in the evaluation of stress fractures, particularly for "return-to-play" assessments 1
• The consideration of special scenarios, such as snowboarder's fracture or bicycle spoke injuries, which may require additional views or imaging studies 1 In terms of management, the approach should prioritize progressive weight-bearing, pain management, and physical therapy to promote proper bone healing and prevent complications. However, the provided evidence primarily focuses on the diagnostic approach rather than the treatment protocol for stress ankle fractures. Given the emphasis on morbidity, mortality, and quality of life, it's crucial to follow the most recent and highest quality guidelines for imaging and managing stress fractures, adapting the approach based on individual patient risk factors and clinical presentation.

From the Research

Ankle Fracture Stressing

When to stress an ankle fracture is a critical aspect of the rehabilitation process. The following points highlight the key considerations:

• Early weight-bearing (within 3 weeks of surgery) may lead to better ankle function, although the difference may not always be clinically important 2.
• A removable ankle support may provide better outcomes, including improved ankle function and health-related quality of life, compared to a non-removable support 2.
• The decision to stress an ankle fracture should be based on the individual patient's condition, including the stability of the fracture and the presence of any complications.
• Routine clinical and radiographic follow-up beyond 16 weeks may have limited utility in asymptomatic patients, and the decision to continue follow-up should be made on a case-by-case basis 3.

Key Considerations

Some key considerations when deciding when to stress an ankle fracture include:

• The type and severity of the fracture
• The patient's overall health and mobility status
• The presence of any complications, such as infection or nerve damage
• The stability of the fracture and the effectiveness of any treatments, such as surgery or casting
• The patient's ability to bear weight and perform daily activities

Rehabilitation Goals

The goals of rehabilitation for ankle fractures include:

• Improving ankle function and mobility
• Reducing pain and discomfort
• Promoting healing and preventing complications
• Restoring the patient's ability to perform daily activities and maintain independence
• Achieving a full recovery and return to pre-injury activity levels 2.