Emergency department reduction and casting of ankle fractures: satisfactory or not?

M.J. Grant, D.M. Machin, H. Carden, S.R. Platt, M.S. Hennessy

Introduction: The initial management of ankle fractures is carried out in the Emergency Department (ED). It is important they are adequately reduced and appropriately splinted in cast to alleviate pain and help protect the soft tissues. Often the ankle is left in an inappropriate position prior to operative intervention.

Methods: 124 consecutive ankle fractures were operated on at a single centre over a 12 month period from March 2012 to April 2013. Radiographs and clinical notes were reviewed by a single foot and ankle surgeon. Reduction and tibiotalar angle in cast were assessed. Neutral tibotalar angle is 115 degrees.

Results: Female:Male 77:47, mean age 49.0, range 14-97. Weber classification was A=1.6%, B = 62.9%, C = 31.5%, isolated medial malleolar fractures = 4.0%. 55.6% of patients had a satisfactory reduction in cast from the Emergency Department. 25.8% of patients reductions were not satisfactory. 14.5% of patients did not have radiographs in cast. 3 patients (2.4%) had fractures that were misdiagnosed initially and therefore were not placed into cast. 13.7% of patients required more than 1 attempt at reduction in the ED. 14 patients (11.3%) required a manipulation in theatre to reduce the ankle after failure in the ED. The range of tibio-talar angles in first cast from the ED was 109-156 degrees, with a mean angle of 128.4 degrees.

Conclusion: Over a quarter (25.8%) of patients did not have satisfactory reduction of their ankle fracture prior to definitive treatment, with 14.5% not having imaging post application of cast. We highlight the importance of the initial management of ankle fractures in the ED. That is, the reduction, appropriate cast application and imaging of the ankle in cast. Our plan is to hold lectures and casting sessions for ED practitioners and junior orthopaedic trainees.