Is it safe to remove a cast for an ankle fracture a week early if it gets soaked?

Cast Removal for Soaked Ankle Fracture

Do not remove the cast a week early simply because it is soaked—instead, replace it with a new cast or convert to a removable orthosis/functional brace, as premature discontinuation of immobilization can compromise fracture healing and increase complications. 1, 2

Immediate Management of the Soaked Cast

• Replace the soaked cast immediately rather than removing immobilization entirely, as moisture compromises the structural integrity of the cast and can lead to skin maceration, infection risk, and loss of fracture reduction 1, 2

• Consider converting to a removable orthosis or functional brace at the time of cast replacement if the fracture has adequate stability and the patient is reliable, as this allows for wound inspection while maintaining immobilization 1, 3, 4

• Use clear dressings and splints or removable casts when possible to facilitate monitoring without requiring cast removal 1

Critical Timing Considerations

• The standard immobilization period for ankle fractures is typically 6 weeks, and removing the cast a week early (at 5 weeks) may be premature depending on fracture type and healing progress 3, 5, 4

• For operatively treated stable ankle fractures, some evidence supports early mobilization after just 3 days with a functional brace, but this requires stable internal fixation and a cooperative patient 5

• For non-operatively treated fractures, maintaining immobilization for the full prescribed period is more critical, as there is no internal fixation to provide stability 2, 6

When Early Conversion to Functional Bracing May Be Appropriate

• If the fracture was operatively treated with stable internal fixation and you are at week 5 of a planned 6-week immobilization, converting to a functional ankle brace (rather than complete cast removal) may be reasonable 3, 4

• The patient must be reliable and cooperative, as early mobilization requires adherence to weight-bearing restrictions and proper brace use 3, 4

• Obtain radiographs before converting to ensure maintained fracture reduction and adequate healing, particularly checking for any loss of reduction that may have occurred under the soaked cast 2, 6

Key Pitfalls to Avoid

• Never simply discontinue immobilization without replacement when a cast becomes soaked, as this creates a gap in fracture protection during a critical healing phase 1, 2

• Beware of loss of reduction under soaked casts, particularly in fractures with posterior malleolar fragments ≥22.5%, which have higher risk of displacement 2

• Avoid premature weight-bearing if converting to a brace early, as the final week of immobilization is still part of the healing process 3, 4

• Watch for wound complications if converting to a functional brace, as this approach has been associated with increased wound-healing complications compared to continued casting (33% vs 8% complication rate) 4

Practical Algorithm

1. Assess fracture stability: Review initial fracture pattern, treatment method (operative vs non-operative), and current week of healing
2. Obtain radiographs: Confirm maintained reduction before any change in immobilization
3. If operatively treated with stable fixation at week 5: Consider conversion to functional brace with continued non-weight-bearing restrictions 3, 5
4. If non-operatively treated or unstable fracture pattern: Replace with new cast to complete the full 6-week immobilization period 2, 6
5. If significant wound concerns exist: Use a windowed cast or removable splint to allow wound inspection while maintaining fracture stability 1