Observations on Closed Reduction of Ankle Fracture- Dislocations with Subsequent Operative Treatment: Predicting the Need for Early Operative Intervention based on Clinical Features of Reduction

Research Article

Foot Ankle Stud. 2017; 1(2): 1008.

Observations on Closed Reduction of Ankle Fracture- Dislocations with Subsequent Operative Treatment: Predicting the Need for Early Operative Intervention based on Clinical Features of Reduction

Matson A1, Zura R2, Green C3 and Hurwitz S4*

1Department of Orthopaedic Surgery, Duke School of Medicine, USA

2Department of Orthopaedic Surgery, Louisiana State University, USA

3Duke University School of Medicine, USA

4University of North Carolina, Department of Orthopaedic Surgery, USA

*Corresponding author: Shepard Hurwitz, University of North Carolina, Department of Orthopaedic Surgery, USA

Received: August 01, 2017; Accepted: September 15, 2017; Published: September 22, 2017

Abstract

Background: Acute ankle fracture-dislocations require emergent reduction. Once the dislocation is successfully reduced, the ideal timing of operative fixation is not agreed upon, in part due to lack of study. At our institution, a protocol enables patients who have a successful closed reduction in the Emergency Department (ED) to go home and return to the clinic to schedule surgery. We sought to describe the rate at which initial reduction is lost between the ED and clinic visits, and to identify factors associated with loss of reduction.

Methods: We retrospectively reviewed all patients who were treated operatively for an ankle fracture from 2008-2013 at a single, Level 1 trauma center and identified 30 patients who had isolated, closed ankle fracture-dislocations that were successfully reduced and splinted in the ED. Adequate reduction was defined by achievement of congruent joint line with <5mm medial clear space. If reduction was maintained at the clinic visit, surgery was scheduled electively, defining a success. However, if reduction was lost in the interim between ED and clinic visits the patient was admitted from clinic for urgent surgical reduction and stabilization, defining a failure.

Results: Seventeen patients (57%) successfully maintained closed reduction and 13 (43%) experienced failure of closed reduction in the interim. Compared to the successful group, the failed group had significantly greater Posterior Malleolus (PM) fracture fragment size (5.1 mm vs. 3.0 mm, p = 0.029). When the ratio of PM fracture fragment size to complete articular surface was >0.1, rate of failure was 65% compared to 18% when the ratio was ≤0.1 (p = 0.016). Other assessments of radiographic and patient factors did not yield any significant difference between the failed and successful groups.

Conclusion: Greater PM fracture fragment size is associated with higher rates of interim failure of closed reduction of closed ankle fracture-dislocations. Injuries with a large PM fracture fragment may warrant consideration of operative intervention at the earliest available time.

Keywords: Ankle fracture-dislocation; Fracture management; Stability; Reduction; Radiographic assessment

Introduction

Closed ankle fracture-dislocations require emergent attention due to the threat of vascular compromise, progression to open fracture, or significant peri-articular soft tissue injury. In the isolated closed ankle fracture-dislocation without vascular compromise, urgent closed reduction is required to restore alignment, decrease soft tissue injury, and relieve pain. If adequate closed reduction cannot be achieved, urgent operative intervention may be warranted to optimize anatomic alignment, reduce further tissue damage and provide fixation [1-3].

In the event of a successful closed reduction, there is no widely accepted protocol for the management of these injuries. For definitive management, Open Reduction and Internal Fixation (ORIF) are well-supported in the literature for most patients [4-6] even if adequate closed reduction is achieved [6].

At our institution, a protocol was developed that enables patients who have a successful closed reduction in the Emergency Department (ED) to go home and return to the clinic in 5-7 days to evaluate soft tissues, obtain x-rays, and schedule elective ORIF. If the reduction is not maintained at this visit, the patient is admitted from clinic to have urgent surgical repair.

Previous studies have investigated factors associated with initial reducibility of closed ankle fracture-dislocations [2,3,7,8], however we are not aware of any study that describes failure to maintain closed reduction over an interval of a few days in these injuries, occurring between ED visit and clinic visit.

The first aim of this study is 1) to describe the rate at which initial reduction is lost in the interim between successful closed reduction in the ED and clinic follow-up. The second aim 2) is to identify patient and radiographic factors associated with loss of reduction. We hypothesized that, compared to successfully maintained reductions, those that that failed in the interim would have greater initial radiographic fracture displacement, greater radiographic evidence of syndesmotic disruption, and/or larger Posterior Malleolar (PM) fracture fragment size. We evaluated demographic and radiographic data in this consecutive series of closed ankle fracture-dislocations in order to support or refute the hypothesis.

Materials and Methods

Prior approval for this retrospective chart review was obtained through an institutional review board.

Criteria

A total of 243 patients underwent operative fixation of an ankle fracture between January 2008 and December 2012 at either the Level 1 trauma center, or the ambulatory surgery center in our health system. Of these patients, 56 had isolated, closed ankle fracture-dislocations that could be classified as bi- or tri-malleolar fractures or fracture-equivalents. Thirty of these patients had injuries that were successfully reduced in the ED and sent to follow-up in clinic. Exclusion criteria included open injuries, concomitant lower extremity fractures, pilon fractures, multisystem trauma requiring hospital admission, fracture-dislocations that failed closed reduction attempts, and fractures that did not require a reduction procedure.

Protocol

All patients presented initially through the ED of a single, Level 1 trauma center. Patients with ankle fracture-dislocations were managed according to a protocol. Closed reduction and plaster splinting were performed by Orthopaedic Surgery residents in the ED with fluoroscopic guidance utilizing an intra-articular block with or without conscious sedation, as described by White et al. [9]. A reduction was considered to be adequate if the post-reduction radiographs showed a congruent ankle joint line with medial clear space <5mm. Reduction was attempted up to 2 times in order to achieve radiographic alignment. If adequate reduction was maintained on standard 3-view post-reduction radiographs, patients were made non-weight bearing, discharged from the ED and scheduled for clinic visits in 5-7 days to arrange elective Open Reduction and Internal Fixation (ORIF). If reductions were unsatisfactory on post-reduction radiographs in the ED urgent operative reduction and ORIF vs. external fixation was performed based on the status of the soft tissues.

Data collection

Charts were reviewed to determine patient demographic data, chronology, and clinical plans. Radiographic data was collected digitally, and measurements were performed using Centricity PACS digital imaging software (GE Medical Systems, Little Chalfont, UK). A single researcher performed the initial measurements on all radiographs included in the study, and these were reviewed and verified by the senior author.

Injury mechanism was determined by the level of the fibula fracture and classified as supination or pronation based on the Lauge-Hansen system [10]. Talus displacement, in both coronal and sagittal plane, was measured and recorded as the percentage of talus uncovered by the tibial plafond. Radiographic length and displacement measurements were made digitally using landmarks described Leeds and Ehrlich [11].