Managing A Radiographically Simple Ankle Fracture In A Complex Patient

This author presents a guide to the surgical treatment of an 83-year-old woman, who suffered a fibular fracture, a presentation complicated by comorbidities and social circumstances.

An 83-year-old female presented in the outpatient clinical setting, demonstrating full-weightbearing in a short, controlled ankle motion (CAM) walking boot despite having a recent unimalleolar (fibular) fracture diagnosed at a local emergency room. She lives alone at home without a consistent local support network. Her medical history is complicated by diabetes mellitus with neuropathy.

Upon initial inspection, her soft tissue envelope was significantly compromised with substantial hemorrhagic and serous fracture blisters. Her vascular status was intact. The patient had diminished sensation in the distal lower extremity that was consistent with diabetic peripheral neuropathy. Her pain was minimal. Weightbearing radiographic images revealed a displaced unimalleolar fibular fracture with moderate displacement and slightly increased medial clear space with questionable fleck avulsion in the medial gutter (see Figure 1). She was not able to demonstrate an appropriate ability to maintain 100 percent strict non-weightbearing on the injured extremity.

At the time of initial clinical evaluation, I determined that it was not safe for the patient to return home. I recommended direct inpatient admission to control the soft tissue envelope and ultimately manage the underlying fracture at a to be determined time. I applied a Sir Robert Jones compression dressing to aid in edema control and fracture stabilization for the direct hospital admission.

Consideration for surgical timing included weighing the risk of complications associated with early treatment of the fracture with regard to the compromised soft tissue envelope versus delayed management of the fracture with regard to exacerbation of deformity, inability to remain non-weightbearing, and lack of insurance coverage for extended care facility placement until surgical care was complete. I determined that pin-to-bar external fixation was not appropriate at this time due to the location of the multiple fracture blisters.

Ultimately after three days of hospitalization with daily applications of serial Sir Robert Jones dressings, the soft tissue envelope had somewhat improved to the point where skin wrinkling was noticeable. However, some of the fracture blisters persisted and a few of the superficial serous fracture blisters perforated (see Figure 2). The patient was medically cleared and optimized for surgery. I determined that the risks associated with discharging the patient home alone non-weightbearing exceeded the risks associated with acute management of the fracture.

As incisional planning is paramount with a compromised soft tissue envelope, I determined that a posterior-lateral approach was most appropriate in order to avoid violating the fracture blisters while providing appropriate access to the fracture and best tissue for layered closure.

After covering the distal extremity with an impervious sterile adhesive sheet to protect the incisional area from the fracture blisters, I manually reduced the fracture via a posterior plating technique. I also employed additional fixation to create a more robust construct consistent with the principles of managing diabetic neuropathic ankle fractures. As one cannot easily apply syndesmotic screws through a posterior plate, I utilized an orthogonal dual plating technique for the placement of multiple quadricortical syndesmotic screws.

The patient was discharged from the hospital to a skilled nursing facility on post-operative day one. I followed the patient at week one, two and four with total contact casting and close monitoring of the fracture blisters and surgical wound progress. There was notable improvement with the fracture blisters and incisional healing at each interval visit (see Figure 3). Ultimately, I casted the patient for eight weeks and she subsequently transitioned to a diabetic controlled ankle motion (CAM) walking boot and advanced to physical therapy for one month to aid in return to general reconditioning and gait training. Subsequent to that, the patient utilized an Arizona Brace (Arizona AFO).

One year after surgery, the patient was able to ambulate without pain or increased deformity (see Figure 4). She has not needed to return to the operating room and intermittently uses the Arizona Brace.

In Conclusion

This case presentation demonstrates a relatively simple radiographic problem with increased complexity when considering patient comorbidities, clinical scenario and social circumstances. Although I did not execute a standard algorithmic approach for management of trauma with a compromised soft tissue envelope allowing time for complete resolution of the fracture blisters in this patient, more aggressive care was warranted when considering the potentially catastrophic complications associated with exacerbation of the fracture blisters or increased/new deformity if surgical management was delayed until the soft tissue envelope normalized in an octogenarian patient who lives alone at home without the ability to safely maintain non-weightbearing status. Adhering to principles with the management of diabetic ankle fractures, I doubled both the fixation while delivering multiple trans-syndesmotic screws and duration of non-weightbearing.

In my practice, anecdotally, I have found more aggressive management of diabetic ankle fractures through the combination of robust locked fixation constructs inclusive of multiple trans-syndesmotic screws, with close post-operative monitoring results in relative fewer complications than traditional fixation constructs or conservative management.

Under-managed diabetic ankle fractures may have a higher incidence of evolution to Charcot arthropathy of the ankle, nonunion/malunion, and requirement for further surgery including ankle fusion and amputation, although this is yet to be clearly reported in the literature. In many cases, even relatively simple fracture patterns in neuropathic, medically comorbid patients can rapidly evolve into cases of limb salvage.

An aggressive early intervention including hospital admission, medical optimization and open reduction internal fixation with robust fixation constructs for even relatively simple fracture patterns can help the surgeon maintain control of the complex situation before it becomes yet more complicated. Further research is necessary to validate these anecdotal impressions, including the most appropriate timing to surgery in patients with diabetic neuropathy and the incidence of complications comparing traditional fixation constructs to more robust “double fixation” constructs. We also need longitudinal studies to evaluate the incidence of Charcot arthropathy based on initial management of the trauma.^1,2

Dr. Prissel is an attending physician at the Orthopedic Foot and Ankle Center in Worthington, Ohio.

References

1.    Manway JM, Blazek CD, Burns PR. Special considerations in the management of diabetic ankle fractures. Curr Rev Musculoskelet Med. 2018;11(3):445-455.
2.    Scheppers T, De Vries MR, Van Leishout EMM, Van der Elst M. The timing of ankle fracture surgery and the effect on infectious complications: a case series and systematic review of the literature. Int Orthop. 2013;37(3):489-494.