Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation

Abstract

Background: Closed reduction and splinting followed by outpatient management is standard of care for temporizing most ankle fractures. However, ankle fracture-dislocation potentially warrants a different approach based on the propensity for loss of reduction. The purpose of this study was to determine the rate of complications associated with closed reduction and splinting of unstable ankle fracture-dislocations. Further, we sought to determine the efficacy of immediate external fixation as an alternative to splinting in cases too swollen for acute operation. Methods: This retrospective chart review analyzed all ankle-fracture dislocations that came through a large health care system from 2008 to 2018. Patients managed with acute open reduction internal fixation (ORIF) and open fractures were excluded. In patients managed late, the cohorts were divided into those temporized with closed reduction/splinting vs external fixation. Reduction quality and splint technique were additionally assessed in splinted patients. A total of 354 closed ankle fracture-dislocations were identified: 298 patients (84%) underwent ORIF within 48 hours and were excluded; 28 (15 female/13 male, average age 46.8 years) were placed in an external fixator and 28 (22 female/6 male, average age 57.2 years) were reduced, splinted, and discharged. Results: At follow-up, 14 of the patients (50%) in the splint group developed loss of reduction and 5 of these patients (17.6%) developed anteromedial skin necrosis from skin tenting. None of the patients in the ex-fix group developed loss of reduction or skin necrosis. The rate of redislocation and the rate of development of skin necrosis was statistically higher in cases temporized with a splint versus an external fixator ( P < .01 and P = .05, respectively). Conclusion: We found that in ankle fracture-dislocations not treated with acute ORIF, splint immobilization was associated with an increased risk of complications, including redislocation and skin necrosis, when compared to a temporizing external fixator. Level of Evidence: Level III, retrospective comparative study.

Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture- dislocation while posterior malleolar fragment size predicts loss of reduction: A Case Control Study

“…Soft-tissue problems associated with temporizing cast immobilization were broadly in keeping with the rates reported by other authors with SSI ranging between 1 to 20% and skin necrosis rate ranging between 4.9 to 8.9% [6, 12,17,24,25,29,30]. Wawrose et al compared 28 patients with temporizing plaster splint immobilization to 28 patients with ex-x following ankle fracture dislocation [30]. The authors found that splint immobilization was associated with a high skin necrosis rate of 17.8% when compared to a temporizing ex-x which yielded 0% skin necrosis.…”

“…Although size of the posterior malleolar fragment does not correlate with clinical and radiological outcomes after ORIF [37], our ndings support the idea that the posterior malleolus is an important indicator for fracture stability of the ankle. Given this result, the substantial difference between our moderate re-dislocation rate of 19.8% within the cast group and an unacceptable high re-dislocation rate of 50% reported by Wawrose et al might be attributed to differences in posterior malleolar fragment sizes between the study groups [30]. It must be noted that, in contrast to our study, patients included in the study by Wawrose et al were discharged after splinting, which makes strict monitoring of the ankle and a prompt reaction to soft-tissue problems di cult.…”

“…Skeletally mature was de ned by a closed physis on ap and lateral X-rays. Ankle fracture-dislocation was de ned as ≥ 50% subluxation of the talus relative to the tibia in one of both planes on the X-ray or when a joint reduction maneuver was successfully performed before the X-ray was taken [30]. Excluded were those with incomplete records, open fractures, immediate de nitive ORIF or treated nonoperatively.…”

Temporarily double-pin external fixator fixation following unstable ankle fracture

“…Lareau et al reported that the use of external xators to temporarily x unstable ankle fractures in emergency department could effectively maintain the temporary reduction and reduce the damage of articular cartilage and soft tissue 18 . There was another temporary reduction method proposed by Richard A. Wawrose et al that the injured ankle was xed with three dimentional external xator which took tibial tuberosity, calcaneus and fore foot as xed points 19 . This kind of methods could provide more stability meanwhile more iatrogenic injuries.…”

Double fibular fracture: An innovative use for elastic stable intramedullary nailing of a distal and proximal fibular fracture

“…The use of interval external fixation significantly reduces the risk of re-dislocation and soft tissue compromise for patients with ankle fracture dislocations. 12…”