Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Long-term Clinical and Radiographic Outcomes Following Surgical Treatment for Ankle Fracture-Dislocations: Do poor radiographic outcomes always matter?

Background Ankle fractures constitute 10% of all traumatic fractures in clinical practice. Concurrent tibiotalar dislocations form 21-36% of all ankle fractures. Although mechanism of injury is similar to non-dislocated ankle fractures, fracture-dislocations cause more extensive bone and soft tissue damage. Treatment is a challenge for orthopedic surgeons due to concomitant pathologies. It is associated with malreduction, chronic pain and most importantly, posttraumatic osteoarthritis. We aimed to investigate the relationship between ankle osteoarthritis radiographic stage and clinical outcomes. Methods 27 patients (17 female, 10 male) were included in the study. Records and data were retrospectively analyzed. Clinical status at the final follow-up was evaluated by a single orthopedic surgeon. Range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analogue scale (VAS) were the clinical parameters that were assessed. Radiological assessment was made by standard anteroposterior [AP], lateral, and mortise views. Pre-operative osseo-ligamentous injury pattern, presence of posterior malleolar fracture, syndesmosis injury and post-operative ankle osteoarthritis were investigated. Results For 27 patients that were evaluated, at the final follow-up, mean AOFAS was 85 ± 8.12, and mean VAS during daily activities was 1.52 ± 0.70. Mean ankle dorsiflexion and plantar flexion were significantly lower on the affected sides (14.07 ± 7.97° and 36.30 ± 6.59°) than on the unaffected sides (28.15 ± 2.82° and 46.30 ± 2.97°), respectively (p < 0.001). No significant difference for inversion and eversion was observed. Twenty-four patients demonstrated radiographic signs of ankle osteoarthritis, and three remained without evidence of osteoarthritis. No significant difference was found among Takakura's stages in any of the variables. Conclusion The results illustrated that although post-traumatic osteoarthritis rate was high for ankle fracture-dislocation patients, surgical treatment achieved excellent functional results. Even if advanced stages of ankle arthritis according to Takakura's classification developed, patients had satisfactory clinical and functional results.

Treatment of Post-traumatic Osteonecrosis in the Distal Tibia With Autologous Bone Grafting: A Case Report.

Osteonecrosis is a disruption of blood supply to the bone which results in bone cell death. Post-traumatic osteonecrosis of distal tibia rarely happens as compared to osteonecrosis which affects other parts of the musculoskeletal system. We report a case of osteonecrosis of distal tibia in an adult male following an open fracture dislocation of the right ankle. Initial surgery of wound debridement with a temporary external fixator was performed for ankle stabilization. The patient underwent internal fixation once the subcutaneous tissue was deemed suitable. A year later, he had worsening ankle pain which affected his daily activities. Magnetic resonance imaging showed osteonecrosis of the distal tibia, osteochondral injury of the medial tibial plafond, and medial talus with lateral ligament complex injuries. Autologous iliac bone grafting was applied to the distal tibia and a cell-free hyaluronic acid-based scaffold (Hyalofast®) was used to address the bone osteonecrosis and osteochondral injury respectively. Visual analog score (VAS), AOFAS hindfoot score, and ankle range of motion improved at three months and significantly increased after six months and one year post-operatively.

Ankle fracture-dislocation with the interposition of the tibialis posterior tendon in the ankle syndesmosis and tibiotalar joint - A case report and systematic literature review.

INTRODUCTION AND IMPORTANCE: In rare cases of ankle fracture dislocation, PTT can be incarcerated in the ankle syndesmosis. We report a case of a patient who had a fracture-dislocation of the ankle with the interposition of PTT in the ankle syndesmosis and discuss a systematic review of injury mechanics, pathology, diagnosis, management, and outcomes of this injury. CASE PRESENTATION: I reported a 43-year-old patient presented with an irreducible lateral displacement of the talus after ORIF of the malleolar ankle fractures and fixation of ankle syndesmosis. Subsequent open reduction and surgical management revealed an interposition of PTT in the syndesmosis 1- month post-operative. A systematic review was completed afterward with the following terms: "ankle fracture" OR "ankle dislocation" AND "tibialis posterior tendon interposition" OR "tibialis posterior tendon entrapment" OR "tibialis posterior tendon incarceration" on Medline, ScienceDirect, and Ovid for articles between 1970 and 2022. CLINICAL DISCUSSION: 5 months postoperative, the patient reported no pain and became capable of walking without a steppage gait. The systematic review showed that the entrapment of PTT could be concurrent with FHL, FDL, and tibial neurovascular. It usually occurs in patients with pronation/eversion injury, Weber C ankle fracture with a valgus deformity and a syndesmosis diastasis. CONCLUSION: The PTT entrapment usually occurs in patients with pronation/eversion injury, Weber C ankle fracture, a valgus deformity, a syndesmosis diastasis. The entrapment of PTT could be concurrent with FHL, FDL, and tibial neurovascular. The tibiofibular syndesmosis and retromalleolar groove should be explored intraoperatively with suspicion of irreducible ankle fracture-dislocations.

Comparing Temporary Immobilization Using Cast and External Fixator in Unimalleolar Ankle Fracture Dislocations: A Retrospective Case Series.

Studies have reported a high percentage of ankle fracture dislocations with secondary loss of reduction during primary treatment with a splint or cast. This study aimed to assess the rate of secondary loss of reduction in unimalleolar ankle fracture dislocations treated primarily with a cast or external fixator, identify the potential influence of fracture morphology, and investigate the potential implications. Unimalleolar ankle fracture dislocations with and without posterior malleolar fracture between 2011 and 2020 were included. Patients were categorized into two groups, depending on the method of temporary treatment. Fracture morphology, time to definitive surgery, and soft-tissue complications were compared. Of 102 patients, loss of reduction tended to occur more often in the cast group (17.3%) than in the external fixator group (6.0%). The presence of a posterior malleolar fracture did not have a significant influence on loss of reduction in cast immobilization; however, the fragment proved to be significantly bigger in cases with loss of reduction. No statistically significant differences in soft tissue complications or time to definitive surgery were found. Surgeons should consider the application of interval external fixation in the primary treatment of unimalleolar ankle fracture dislocations with additional posterior malleolar fractures.

Fractura-luxación abierta de tobillo y fractura de tibia

Introducción: La incidencia de fractura-luxación abierta de tobillo es baja, lo que hace que su combinación con fractura del tercio distal de la tibia sea grave y muy compleja de tratar. Constituye una entidad causada por traumas de alta energía y se asocia a lesiones neurovasculares. Objetivo: Presentar un caso grave y complejo de fractura-luxación abierta de tobillo y fractura del tercio distal de la tibia. Caso clínico: Paciente masculino de 33 años de edad, que ingresó en el servicio de ortopedia y traumatología de urgencia, por haber sufrido trauma directo en el acople de 2 vagones de un tren. Presentó fractura-luxación tibioastragalina abierta III-B, asociado a fractura oblicua del tercio distal de la tibia y el peroné del miembro inferior izquierdo. Fue intervenido quirúrgicamente de urgencia. Se realizó amplio desbridamiento quirúrgico, reducción de la luxación, fijación del maléolo tibial, reparación primaria de las lesiones ligamentosas y estabilización externa para artrodesis precoz. El paciente evolucionó con infección de la herida quirúrgica, para lo cual necesitó de curas secuenciales y oxigenación hiperbárica. Se recuperó a los 8 meses. Conclusiones: La fractura-luxación abierta de tobillo y fractura del tercio distal de la tibia es una combinación poco frecuente, grave y compleja de tratar. Obedece a traumas de altas energías. La cirugía de urgencia, la profilaxis antimicrobiana y la oxigenación hiperbárica, contribuyeron al tratamiento definitivo de este paciente.

Introduction: The incidence of open ankle fracture-dislocation is low, which makes its combination with a fracture of the distal third of the tibia serious and very complex to treat. It is an entity caused by high-energy trauma and is associated with neurovascular injuries. Objective: To present a serious and complex case of open ankle fracture-dislocation and fracture of the distal third of the tibia. Clinical case: A 33-year-old male patient, who was admitted to the emergency orthopedics and traumatology service, for having suffered direct trauma in the coupling of two train cars. He presented an open tibiotalar fracture-dislocation III-B, associated with an oblique fracture of the distal third of the tibia and fibula, of the left lower limb. He underwent emergency surgery; Extensive surgical debridement, reduction of the dislocation, fixation of the tibial malleolus, primary repair of the ligamentous injuries, and external stabilization for early arthrodesis were performed. The patient evolved with infection of the surgical wound, for which he needed sequential dressings and hyperbaric oxygenation. Full recovery at 8 months. Conclusions: Open ankle fracture-dislocation and fracture of the distal third of the tibia is a rare, serious and complex combination to treat. Due to high energy trauma. Emergency surgery, antimicrobial prophylaxis, and hyperbaric oxygenation contributed to the definitive treatment of this patient.

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.

BACKGROUND: To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries. METHODS: All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed. RESULTS: In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001). CONCLUSION: Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size. TRIAL REGISTRATION: The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Early posttraumatic ankle osteoarthritis following ankle fracture-dislocations in a sub-Saharan African setting.

INTRODUCTION: Ankle fracture-dislocation (AFD) represents a major threat to the joint and a potential source of complication and functional disability. This study was performed to assess the outcome of AFD in a resource-limited setting and factors associated with the posttraumatic ankle osteoarthritis (PTAOA). We hypothesized that conservative treatment after AFD was associated with higher risk of PTAOA compared to surgical treatment. PATIENTS AND METHODS: Data from 52 consecutive patients (mean age 37.2±11.1years, with 57.7% n=30, males) who were treated and followed in a teaching hospital for AFD during a period of six years were collected. Forty-four of these patients were obtained at the time of the study for a retrospective evaluation. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS), ankle-hindfoot scale, and the patient's global satisfaction index. Radiographs were performed and analyzed for PTAOA. Logistic regression was used to determine factors associated with the presence of PTAOA. RESULTS: PTAOA was found in 19 (43.2%) patients after an average follow-up period of 27.2±18.3months. Anatomic fracture reduction was achieved in 22 (50%) patients, while the talus was centered in the mortise in 30 (68.2%) patients. Despite these poor anatomical results, the clinical outcome was good to excellent in 33 (75%) patients, and 88.6% was satisfied or very satisfied. Factors associated with the presence of PTAOA were the non-anatomical reduction (OR=11.07; p=0.007, 95% CI: 2.096-58.77) and the time elapsed since trauma (OR=1.073; p=0.007, 95% CI: 1.109-1.129). CONCLUSION: This study indicates that AFDs are associated with high rate of early and severe PTAOA. Non-anatomical realignment and a delay since trauma were positive predictors of PTAOA. There was no difference regarding the occurrence of PTAOA after AFD whatever the type of treatment, surgical or conservative. LEVEL OF EVIDENCE: IV; retrospective cohort study.

Avoiding pitfalls in ankle fracture-dislocations: A case report of a dislocated tibialis posterior tendon causing persistent ankle subluxation.

Tibialis posterior tendon dislocation, a rare complication in ankle fracture-dislocations, can impede anatomical reduction of the ankle mortise. We report on a 59-year-old healthy male with an open fracture-dislocation of the right ankle. Despite multiple attempts under direct vision of the anterior syndesmosis, anatomical reduction of the ankle mortise was not possible. Soft tissue windows in a computed tomography (CT) scan revealed the dislocated tibialis posterior tendon to be the impeding structure. At the level of the fibula fracture the tendon passed through the interosseous membrane anterior to the distal tibia and was then incarcerated in the medial talocrural joint before returning to the flexor retinaculum and its insertion on the navicular bone. Understanding the trauma mechanism and the course of the dislocated tendon as well as correct interpretation of CT and magnetic resonance images of the ankle enable surgeons to early diagnose and correctly treat this condition.

Irreducible Ankle Fracture Due to Incarceration of the Long Flexor Tendons Together With the Neurovascular Bundle in the Tibial Fibular Interosseous Space: A Case Report and Short Literature Review.

Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities.

Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation.

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.

Posterior malleolus fractures in Bosworth fracture-dislocations. A combination not to be missed.

OBJECTIVES: Posterior malleolar fractures (PM) have been linked to inferior outcome in malleolar fractures. This study aims to analyze the prevalence and pathoanatomy of PM fractures in Bosworth fracture-dislocations (BF). MATERIALS & METHODS: Radiographs and computed tomography (CT) scans of 13 patients treated at our institution and 97 cases published between 1947 and 2018, identified in a systematic literature search, were evaluated with respect to the pathoanatomy of BF. In all 13 cases from the present study and in 10 cases from the literature, axial CT scans were performed. RESULTS: All 13 patients (100%) with BF from the present series and 61 of 97 documented cases (63%) of BF from the literature were associated with a PM fracture. In patients with a complete CT analysis, dislocation of the fibula behind the posterior tibial rim was associated with extraincisural (Bartonícek / Rammelt type 1) PM fractures. Displacement of the fibula between the displaced PM fragment and the tibia was associated with Bartonícek / Rammelt types 2 and 3 PM fractures. CONCLUSIONS: Seventy prevent of all reported BF are associated with a PM fracture. The true prevalence may be even higher because of the historically infrequent use of CT imaging. The pathoanatomy of the PM fragment is highly variable as is the kind of fibular displacement in BF. Therefore, CT scanning should be performed routinely in BF. Displaced PM fractures in BF involving the incisura should be treated operatively via a direct posterolateral approach.

[The irreducible ankle dislocation: beware of the Bosworth injury]. / Irreponible Luxation des oberen Sprunggelenks: die Bosworth-Verletzung.

A luxation fracture of the ankle characterized by a dislocation of the fibula posterior to the tibial tubercle is defined as a Bosworth injury. The Bosworth fracture is a frequently overlooked complex injury of the ankle joint. Associated injuries such as a pilon fracture and posterior malleolus fracture have rarely been reported. In the case of a closed irreducible ankle fracture dislocation, Bosworth injuries should be considered as a potential cause. This article reports the course, treatment and clinical outcome 12 months after trauma of a Bosworth fracture with associated impaction of the posteromedial pilon and fracture of the posterior malleolus. To date, there are only few reports of comparable injuries in the German language literature.

Fracture dislocation of the ankle with posterior tibial tendon entrapment within the tibiofibular interosseous space: A case report.

In rare cases of ankle fracture dislocation, the posterior tibial muscle tendon (TP tendon) is incarcerated between the tibia and fibula, thereby impeding reduction. Here we describe a case that presented with such a condition, in which ankle reduction was achieved and surgical repair of the incarcerated TP was delayed. The subject was a 30-year-old male who sustained a fracture dislocation of the left ankle (AO:44-C1.3) in a motorbike accident. After repairing the ankle dislocation, external fixation was performed and osteosynthesis was conducted 10 days after the injury. Plate fixation for the fibula fracture and tight rope fixation for the separation between the tibia and fibula were performed; however, internal fixation for the medial malleolus fracture was delayed because the skin on the medial side of the ankle was in poor condition. One month after the injury, osteosynthesis of the medial malleolus was performed, and the TP tendon was identified in the fracture site. After removing the incarcerated tendon, good reduction of the medial malleolus was achieved, and thus, internal fixation and wound closure could be performed. Re-examination revealed that the TP tendon had an abnormal course. After 3 months, upon re-exposing the entire length of the TP tendon, the TP tendon was incarcerated between the tibia and fibula. To date, although several cases have been reported regarding TP tendon incarceration caused by fracture dislocation of the ankle, no study has reported the anatomical repair of the ankle, regardless of tendon incarceration. In our case, rotational displacement of the medial malleolus fracture remained when the second surgery was completed; however, the presence of some type of incarcerated tissue was suspected. Because leaving the incarcerated TP tendon untreated can cause irreversible long-term complications, early anatomical repair is recommended.

Irreducible ankle fracture dislocation due to posterior tibialis tendon interposition: Diagnostic and clues for early management - A case report.

Irreducible fracture dislocation of the ankle is a rare condition. Multiple cases have been described throughout the literature. Different known etiologies involve the distal fibula, deltoïd ligament and tendons of the posteromedial malleolar region. More specifically, trapping of the Posterior tibialis tendon has been described at several levels from the inside of the ankle joint, through the syndesmosis and in some cases in the fibula tibial interosseous space depending on the energy of trauma. We hereafter propose a case report and a review of previous cases of posterior tibialis tendon dislocation proximally in the interosseous space of the lower leg. The aim of this review is to point out common features and clues for early management in order to avoid overlooking these rare lesions as they may lead to major functional impairment of the ankle joint.

An uncommon case of irreducible ankle fracture-dislocation: the "Bosworth-like" tibio-fibular fracture.

An irreducible ankle-fracture dislocation characterized by the dislocation of the proximal fragment of the fibula posteriorly to the tibial tubercle is defined as "Bosworth injury". In the present report it is described, for the first time in literature, a complex case where the Bosworth injury was associated to a tibial plafond fracture: the proximal fibular fragment was entrapped between the tibial pilon and the fractured posterior tibial tubercle, which acted as a clamp, thus avoiding ankle reduction. Due to the presence of the tibial fracture, it was not possible to observe the typical radiological signs of Bosworth injury and therefore two unsuccessful reductions were attempted before performing a CT scan that revealed the complexity of the case, that required an immediate ORIF procedure to prevent the onset of complications.

Ankle injury manipulation before or after X-ray--does it influence success?

Many acute, deformed ankle injuries are manipulated in the Emergency Department (ED) before X-rays are taken to confirm the nature of the injury. This often occurs in the absence of neurovascular or skin compromise without consideration of other possible injuries such as talar, subtalar or calcaneal injuries. We believe that an inappropriate manipulation of an unknown injury pattern may place the patient at increased risk. A balance needs to be struck between making the correct diagnosis and preventing any further neurovascular or skin compromise. We prospectively reviewed 197 patients admitted to the Royal Blackburn Hospital with acute ankle injuries. Their ED notes were reviewed, specifically assessing whether a manipulation was performed; if so, was it performed before X-rays and the documented reasons. A total of 90 ankle fractures were manipulated and 31 of these were performed before X-ray. One manipulation was performed for vascular compromise, one for nerve symptoms, three for critical skin and 25 for undocumented reasons. Outcomes (re-manipulation, delay to surgery and need for open reduction and internal fixation (ORIF)) were compared between injuries manipulated before or after X-ray. Re-manipulation was found to be significant (44% before X-ray vs. 18% after X-ray; chi-squared test: p=0.03; relative risk (RR)=2.72; 95% confidence interval (CI): 1.15-6.44). Delay to surgery and need for ORIF were not statistically different. We conclude that performing ankle injury X-rays before an attempt at manipulation, in the absence of neurovascular deficit or critical skin, may constitute best practice as it provides a better assessment of fracture configuration, guides initial reduction and significantly lowers the risk of re-manipulation and the potential risks associated with sedation without delaying surgery.