Only 25% of ankle fractures are displaced, although they occupy most of the literature and textbooks.
Residual mortise incongruity increases the risk of late osteoarthritis, although many patients with some incongruity or even OA have few symptoms. Therefore, the goal of treatment is to restore tibiotalar congruity, maintain this until fracture union and provide opportunities for rehabilitation. Even with optimum treatment, most patients will have some residual symptoms at long-term follow-up and they need to be advised of this before treatment begins.
Initial management includes:
Traditionally, most displaced ankle fractures were managed by closed reduction and casting, with prolonged nonweightbearing and follow-up radiography. Early internal fixation techniques emphasised stabilisation of the medial malleolus with screws, believing that the lateral malleolus contributed little to ankle stability. In 1977, Yablon published a group of biomechanical and clinical observations which led him to the conclusion that “the talus follows the lateral malleolus” and that the key manoeuvre in internal fixation of the ankle was accurate reduction and stable fixation of the lateral malleolus. Yablon’s work, along with stable fracture fixation techniques through the AO school, has led to open reduction and internal fixation of most ankle fractures as a standard technique. What is the evidence to support this change?
There are four randomised controlled trials comparing ORIF with closed reduction and casting (Bauer 1985, Phillips et al 1985, Rowley and Duckworth 1986, Makwana et al 2001). Makwana’s trial included only patients over the age of 55, and was the only trial to show any functional advantage at long-term follow-up for surgically treated patients. Bauer's trial, which is the best methodologically, showed no difference at 6-8 years between patients treated surgically or by closed reduction and casting, but the surgical group recovered quicker. Rowley found that surgically treated patients took longer to recover normal movement and gait. Phillips’ paper is often quoted to show better outcomes in surgically treated patients, but in fact the clinical outcomes were the same – only the radiological outcomes were better after surgery.
These studies should not be taken to show that ORIF is unnecessary. For one thing, the post-operative management was restrictive (only Rowley et al allowed early weightbearing and none allowed early movement to surgically treated patients). Outcome measures were non-standardised and there was significant loss to follow-up in Phillips’ and Makwana’s series. In addition, there were patients in each series (10-30%) who could not be managed closed and required ORIF. Further trials, using modern methods of post-operative care, may show additional advantages for surgery.
However, this data would suggest that if the talus can be maintained under the tibia closed reduction and casting is an acceptable method of treatment. ORIF would be strongly indicated for:
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