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Ankle fracture

Definition
Ankle fractures refer to a fracture in any of the three bones comprising the ankle joint: the lateral or posterior malleolus of the tibia, medial malleolus of the fibula, and/or the talus.
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Pathophysiology
Common causes of ankle fractures include trauma from falls, sports injuries, and twisting of the ankle. The primary mechanisms of ankle fractures are rotational injuries and supination or pronation movements.
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Disease course
Clinically, patients with ankle fractures often present with pain, swelling, and bruising in the ankle area. They may also have difficulty bearing weight on the affected side.
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Prognosis and risk of recurrence
The prognosis of ankle fractures can vary based on the severity of the fracture and the patient's adherence to rehabilitation. Complications such as posttraumatic arthritis or chronic instability can occur. In some cases, surgical intervention may be required, particularly for complex fractures.
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Key sources
The following summarized guidelines for the evaluation and management of ankle fracture are prepared by our editorial team based on guidelines from the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2023), the American College of Radiology (ACR 2020), the British Medical Journal (BMJ 2017), the British Orthopaedic Association (BOA 2016), and the American Academy of Family Physicians (AAFP 2016; 2012).
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Guidelines

1.Classification and risk stratification

Ottawa ankle rule: use the Ottawa Ankle Rule to rule out fractures and prevent unnecessary radiographs in patients with suspected ankle sprain.
A
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2.Diagnostic investigations

History and physical examination
Assess for the mechanism of injury and clinical findings, including skin integrity, circulation, and sensation at presentation.
B
Assess for comorbidities that might influence treatment choice and outcome, including preexisting mobility impairment, diabetes mellitus, peripheral neuropathy, peripheral vascular disease, osteoporosis, renal disease, smoking, and alcohol abuse.
B

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3.Medical management

Pain management
Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture.
C
Insufficient evidence to recommend the preferential use of either selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs.
I

4.Therapeutic procedures

Reduction and splinting: offer analgesia and splinting and allow bearing weight as tolerated in patients with a stable ankle fracture. Avoid obtaining further follow-up.
B
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5.Perioperative care

Perioperative antibiotics
Administer antibiotic prophylaxis as soon as possible to reduce wound infections in open fractures.
B
Do not administer long-term antibiotic therapy (7-10 days) to reduce open fracture wound infection rate.
D

6.Surgical interventions

Indications for surgery
Perform surgery to achieve reduction and stabilization of the ankle mortise. Assess the syndesmosis and stabilize if unstable. Obtain intraoperative radiographs to confirm reduction.
B
Perform early fixation (on the day or day after injury) in most patients aged < 60 years with unstable ankle mortise. Consider performing external fixation in case of gross instability associated with soft tissue compromise.
B

7.Follow-up and surveillance

Follow-up
Review patients within 2 weeks with further radiographs (weight bearing if possible) to confirm the position remains acceptable in fracture patterns where stability is uncertain.
B
Follow-up patients after surgery within 6 weeks of surgery to detect complications and confirm maintenance of reduction on radiographs.
B

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