Malleolar Fractures


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Malleolar Fractures


Daniel Axelrod MD1, and David W. Sanders MD FRCSC2


1Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


2Division of Orthopaedic Surgery, Western University, London, ON, Canada


Clinical scenario



  • You are on call and are asked to see a 23‐year‐old male who has suffered a rotational ankle injury after slipping on ice. The triage nurse asks if he should receive an x‐ray before you see him and what clinical tools might be appropriate to decide that.
  • Once the x‐rays have been completed and you speak to the patient, you mention that he may have an injury to his ankle syndesmosis. The patient asks what various options there may be for treatment.
  • You also notice on the lateral x‐ray that the patient has a small posterior malleolus fracture. You are unsure if you should fix the posterior malleolus as it seems small. You wonder if adding additional fixation will improve this patient’s outcomes.

Top three questions



  1. Amongst adult patients presenting with low‐energy inversion ankle injuries, are the Ottawa Ankle Rules (OAR), when compared to other ankle injury screening tools, more accurate in diagnosing patients with ankle fractures?
  2. Amongst adult patients, who have syndesmotic injuries proven with intraoperative stress testing, do novel suture button devices, when compared to standard screw fixation, improve the reduction of syndesmosis and patient‐reported outcomes?
  3. Amongst adult patients who have posterior malleolar ankle fracture, at what percentage of articular surface involvement does operative intervention, when compared to nonoperative management, yield improvement in patient‐reported outcomes at one‐year follow‐up?

Question 1: Amongst adult patients presenting with low‐energy inversion ankle injuries, are the Ottawa Ankle Rules (OAR), when compared to other ankle injury screening tools, more accurate in diagnosing patients with ankle fractures?


Rationale


Ankle injuries are among the most common reasons for visits to the Emergency Department.1 Many patients do not require radiographic imaging, adding unnecessary cost and increasing wait times in the Emergency Department. Multiple screening tools have been developed to triage which injuries are at high risk for fractures and will require radiological investigation.2


Clinical comment


In order to deliver healthcare effectively, it is important to identify which patients require imaging in the Emergency Department and those that can be managed conservatively and discharged immediately. Furthermore, the most utilized decision‐making tool (the OAR) was initially validated more than 25 years ago and primarily used at that time by emergency physicians.3 Modern primary care involves associated healthcare professionals, including nurse practitioners and physiotherapists. Accordingly, the most accurate screening tool needs to be one that is appropriately utilized by all healthcare professionals.


Ottawa Ankle Rules3


Ankle radiographs are indicated if there is pain in the malleolar area and any of the following:



  • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.
  • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.
  • An inability to bear weight, both immediately and in the Emergency Department, for four steps.

Available literature and the quality of the evidence


The most relevant current literature consisted of:



  • Level I: 2 randomized trials.2,4
  • Level I: 2 systematic reviews of the literature and meta‐analysis of comparative studies.5,6

Findings


Various decision‐making tools regarding ankle fracture assessment have been reviewed in a number of prospective studies and a recent systematic review. In a 2015 randomized controlled trial (RCT), the OAR were shown to have better specificity than the Bernese Ankle Rules, at 0.97 and 0.69.2 In a 2018 RCT, triage nurses using the OAR were able to detect ankle fractures more often than physicians using expertise alone.3 Additionally, the proportion of ankle fractures missed was lower in the triage nurse group than the physician group. This study highlighted the ability to apply the OAR to a variety of healthcare professionals, not just emergency room physicians.4


Additionally, 66 studies evaluating the OAR were included in the most recent systematic review and meta‐analysis.5 Overall sensitivity of the OAR was found to 99.4%, while use of the OAR was found to reduce unnecessary medical imaging by ∼30% across all settings and by 49% in sports centers.


When compared to other screening tools, a recent meta‐analysis showed the OAR, Bernese Ankle Rules, and the Malleolar Zone Algorithm to result in a negative likelihood ratio of 0.12, 0.14, 0.39, and 0.23, respectively – highlighting that the OAR remains the most accurate decision tool for excluding fractures in the setting of an acute injury.6


Resolution of clinical scenario



  • Level I evidence that the OAR are an accurate screening tool to exclude fracture in adult patients presenting with ankle fractures. These rules decrease use of radiography with a low likelihood of missing a fracture (overall quality: high).
  • Level I evidence that the OAR are superior to other screening tests in excluding ankle fractures(overall quality: high).

Question 2: Amongst adult patients, who have syndesmotic injuries proven with intraoperative stress testing, do novel suture button devices, when compared to standard screw fixation, improve the reduction of syndesmosis and patient‐reported outcomes?


Rationale


One of the promising aspects of suture button fixation for syndesmotic injuries is the ability to maintain reduction while allowing a small degree of motion of the syndesmosis once patients begin to weight bear, and a relative reduction in hardware‐related complication compared to screw fixation.7 Accordingly, it is important to understand if suture button fixation achieves its purported goals.


Clinical comment


The distal tibiofibular syndesmosis is a primary stabilizer of the ankle joint. Instability of this articulation has been shown to significantly increase joint contact pressures and thus predispose to secondary arthrosis and poor functional outcomes.8

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Malleolar Fractures

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