What is the management of ankle fractures in the Emergency Department (ED)?

From the Guidelines

Ankle fracture management in the emergency department should prioritize a systematic approach focusing on assessment, stabilization, and appropriate disposition, with initial management including a thorough neurovascular examination, pain control, and immobilization with a posterior splint or sugar-tong splint. The initial assessment should include the use of the Ottawa Ankle Rules (OAR) to determine the need for radiographic evaluation, as recommended by the American College of Radiology 1. Key aspects of management include:

• Pain control with medications like ibuprofen 400-600mg or naproxen 500mg for mild to moderate pain, or morphine 0.1mg/kg IV for severe pain
• Immobilization with a posterior splint or sugar-tong splint to maintain the ankle in a neutral position at 90 degrees
• Radiographic evaluation with standard ankle views (anteroposterior, lateral, and mortise views) to determine fracture pattern and stability
• Open fractures require immediate orthopedic consultation, tetanus prophylaxis if indicated, and intravenous antibiotics such as cefazolin 2g (or clindamycin 600mg if penicillin-allergic), with a short course of antibiotic prophylaxis recommended to prevent surgical site infections (SSI) 1
• Unstable fractures with significant displacement or those involving the syndesmosis typically require orthopedic consultation for potential surgical intervention
• Stable, non-displaced fractures can often be managed with immobilization and outpatient orthopedic follow-up within 5-7 days
• Patient education should include elevation instructions, ice application for 20 minutes every 2-3 hours, non-weight bearing status on the affected limb, monitoring for compartment syndrome signs, and clear follow-up instructions. The use of local antibiotics, such as antibiotic beads, and coating of internal fixation devices with gentamicin may also be beneficial in preventing infections 1. Overall, the management of ankle fractures in the emergency department requires a careful and systematic approach to ensure optimal outcomes and minimize complications.

From the Research

Ankle Fracture Management in the Emergency Department

• Ankle fractures are a common musculoskeletal injury seen in emergency departments and minor injury units, with long-term disability resulting from ankle fractures able to be reduced by optimal early management procedures 2.
• A study of 236 patients with acute ankle fractures found that 52% of patients had definitive surgery within 24 hours of their injury, with 24% of patients requiring essential manipulation prior to surgery 2.
• The use of a removable type of immobilisation combined with exercise has been shown to significantly reduce activity limitation, reduce pain, and improve ankle dorsiflexion range of motion after surgical fixation 3.
• However, this approach also led to a higher rate of mainly minor adverse events, highlighting the importance of considering the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise 3.
• Early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation are supported by limited evidence 3.
• Guidelines from NICE and the British Orthopaedic Association provide an overview of the key perioperative factors that need to be considered in cases of ankle fracture, including the decision to weight-bear early after surgery and the use of virtual fracture clinics 4.
• A review of best practice for the assessment and management of common ankle and foot injuries in the emergency department found that the quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient 5.
• The use of the Ottawa ankle rules is recommended as part of a thorough history and physical examination to guide ED treatment, specialist referral, and follow-up plan 5.

Key Considerations

• Optimal early management procedures are crucial to reduce long-term disability resulting from ankle fractures 2.
• The patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential 3.
• Early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation are supported by limited evidence 3.
• Guidelines from NICE and the British Orthopaedic Association should be considered when managing ankle fractures 4.
• The Ottawa ankle rules should be used as part of a thorough history and physical examination to guide ED treatment, specialist referral, and follow-up plan 5.