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ABSTRACT

INTRODUCTION: Malleolar fractures are one of the most common fractures in

orthopaedic traumatology. As with all intra articular fracture, malleolar fracture

necessitate accurate reduction and stable internal fixation. When malleolar fractures

are not reduced accurately they may lead to post traumatic painful restriction of

motion or osteoarthritis or both.

OBJECTIVE: To determine the functional outcome (mean modified ankle score of

Olerud and Molander) following open reduction and internal fixation of unstable

ankle fracture

STUDY SETTING: The study was conducted at Orthopedic Department, CMH

Hospital, Lahore.

DURATION OF STUDY: March 16, 2021 to September 16, 2021

STUDY DESIGN: Descriptive case series

SUBJECTS & METHODS: Total 60 patients with unstable ankle fractures were

enrolled in the study. They underwent open reduction and internal fixation as per

standard method. Following surgery, they were provided care as per departmental

protocols. At 12 weeks follow up, they were assessed for modified ankle score of

Olerud and Molander by the same surgical team. The collected data were entered and

analyzed accordingly using SPSS v25.0. Final outcome (mean modified ankle score

of Olerud and Molander) was stratified for age, gender, side of injury, duration since

injury and BMI. Post-stratification, Student’s t-test was applied. A p-value ≤0.05 was

considered as significant.
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RESULTS: Total 60 patients with unstable ankle fracture were selected for this

study. Mean age of patients was 43.80±15.55 year. There were 42(70.0%) male and

18(30.0%) female patients. Mean modified Olerud and Molander ankle score among

patients with unstable ankle fracture after 3 months of open reduction and internal

fixation was 79.67±9.15.

CONCLUSION: Operative treatment for ankle fractures results in good functional

outcome post-operatively. Anatomical reduction of the fracture is associated with

better functional outcome. Early treatment without delay, anatomic reduction and

fracture fixation, stringent post-operative mobilization and rehabilitation should help

improve outcome in an operated ankle fracture.

KEY WORDS: Ankle Fracture, ORIF Approach, Modified Olerud and Molander

Ankle Score.
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INTRODUCTION

Ankle fractures are one of the most common lower extremity injuries, affecting all

age groups. Unstable ankle fractures are usually treated surgically in an effort to

prevent posttraumatic arthritis and thereby maximize functional recovery. However,

the optimal timing of operative treatment for ankle fracture surgery remains uncertain.

Early surgery within 24 to 48 hours after injury may provide some benefit, reducing

the risk of wound complications and the duration of admission if the patient is

admitted to the hospital, although many ankle fracture patients are treated as

outpatients in the United States.1-2

Surgery performed too soon after injury might have an increased risk of wound

healing problems secondary to severe swelling; surgery performed too late may result

in some difficulty obtaining an anatomical reduction. However, some studies have

suggested no increased risk of complications with delayed surgery. 3-4 Surgical and

conservative management of displaced or unstable ankle fractures produce

comparable short-term functional outcomes. The higher risk of early treatment failure

and malunion/non-union in the conservative group versus higher rates of further

surgery and infection in the surgical group should be considered.

Trials are being conducted to assess short and longer-term results and functional

outcomes of these patients and inform management of select patient groups. 5-7

Although postsurgical complications and functional assessment are important to study

clinical results, complications of lower-limb injuries are less frequently considered,

especially in the elderly. Several criteria can assess treatment results and the

socioeconomic impact, such as (1) self-sufficient mobilization, (2) time of recovery,

(3) duration of physiotherapy, and (4) duration of pain management. 8-9

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In a previous study, outcome was determined using mean modified ankle score of

Olerud and Molander and it was 47.55±17.92 at 3 months follow up. 8 Ankle fractures

in older people are increasing in number as the population ages Although ankle

fractures like all other lower limb fractures pose a serious illness and have high

impact over quality of life of the patients.

Still, there is limited evidence on which injury, treatment and socio-demographic

factors predict functional outcomes after ankle fracture and particularly studies using

a structured scale on unstable ankle fractures are scarce. Therefore, I want to conduct

this study to observe functional outcome of open reduction and internal fixation.

Following this study, we will be able to guide and educate our patients regarding

expected outcomes.
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REVIEW OF LITERATURE

The procedure for evaluation and management of open fractures is best described as a

set of principles that has evolved over time, often in relation to advances in wartime

care of military personnel. These principles involve both initial management and

subsequent surgical intervention.10-11

The first step is accurate diagnosis and documentation of the mechanism of injury.

Appropriate coverage of the wound and splinting of the fracture are performed in

conjunction with initiation of appropriate antibiotic therapy and tetanus

prophylaxis. Broad coverage for gram-positive organisms with the addition of gram-

negative coverage for higher-grade injuries has become the most common choice for

initiation of antibiotic therapy after open fracture.

Urgent surgical intervention typically follows and involves both soft-tissue and bone

management. Adjuncts to the care of open fractures have evolved and often involve

delivery of antibiotics or metabolically important substances to the local fracture

environment.
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PATHOPHYSIOLOGY

The risk of a fracture being open is related to the amount of soft-tissue coverage in

that region of the body and to the amount of energy imparted to that region. For

example, the tibia has a long medial aspect that is subcutaneous, and therefore, it is

“easier” for trauma to the lower leg to expose the bone and fracture site. Conversely,

the femur is surrounded by thick muscle layers circumferentially and, therefore, is less

likely to be exposed after a similar amount of force to the thigh.

Open fractures pose some unique risks beyond those encountered with similar closed

fractures that may occur with similar amounts of force. The greatest problem is the

risk of infection. Diaphyseal bone loss in excess of 3 cm presents a complex set of

problems as well. If the open fracture was caused by penetrating trauma, direct injury

to major neurovascular structures may be more likely, thereby affecting the prognosis

for limb function.

Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture

management. Furthermore, bacteria can colonize wounds at later stages of care, being

introduced into the wound at subsequent dressing changes or repeat debridements

prior to definitive wound closure. Gustilo and Anderson reported that 50.7% of their

158 patients had a positive wound culture upon initial evaluation. 12

Another 31 patients that were initially culture-negative had a subsequent positive

culture at the time of their definitive closure. Devitalized tissue results from the

energy imparted to the body. A crushing injury can impair the local immune response,

with local ischemia playing a large role in this process.

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Ischemia may also occur by direct trauma to the large vessels and/or microcirculation.

Important indirect causes of ischemia include increased myofascial compartment

pressures, increased vascular permeability, and the use of vasoconstrictive

medications during resuscitation.

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HISTORY AND PHYSICAL EXAMINATION

Open fractures occur in many ways, and the location and severity of the injury are

directly related to the location and magnitude of the force applied to the body.

Clearly, this involves a broad spectrum of clinical scenarios.

In the most benign form, an open fracture may involve a very small wound caused by

a sharp bone spike, creating a small, minimally contaminated hole in the overlying

skin. The opposite end of the spectrum may involve high-velocity gunshot wounds,

vehicular trauma, or industrial accidents with associated tissue crushing and

devitalization.
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CLASSIFICATION

Gustilo-Anderson classification

Internationally, for adult and pediatric patients, the modified Gustilo-Anderson

classification is widely used.12 Their initial description was published in 1976, as

follows:

 Type I - Open fracture with a wound less than 1 cm in length, and clean

 Type II - Open fracture with a laceration more than 1 cm in length, without

extensive soft-tissue damage, flaps, or avulsions

 Type III - Either an open segmental fracture, an open fracture with extensive

soft-tissue damage, or a traumatic amputation

The description of type III fractures was subsequently further refined and described

by Gustilo et al in 1984,13 as follows:

 Type IIIa - Severe comminution or segmental fractures, but with adequate

coverage of bone and a wound that is closeable by simple means

 Type IIIb - Extensive soft-tissue damage in association with the open fracture,

with significant bone exposure and periosteal stripping, typically requiring

tissue rotation or free tissue transfer for closure

 Type IIIc - Any open fracture with an arterial injury that requires repair

It is important to note that the severity of the injury may not be fully appreciated at

the time of initial evaluation, and therefore, classification should be based on the

intraoperative findings.
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Orthopaedic Trauma Association classification

The Orthopaedic Trauma Association (OTA) published a fracture and dislocation

classification compendium, according to which open fractures are categorized on the

basis of five main variables: skin injury, muscle injury, arterial injury, contamination,

and bone loss.14

Skin injury is quantified as follows:

1. Laceration with edges that approximate

2. Laceration with edges that do not approximate

3. Laceration associated with extensive degloving

Muscle injury is quantified as follows:

1. No appreciable muscle necrosis, some muscle injury with intact muscle

function

2. Loss of muscle but the muscle remains functional, some localized necrosis in

the zone of injury that requires excision, intact muscle-tendon unit

3. Dead muscle, loss of muscle function, partial or complete compartment

excision, complete disruption of a muscle-tendon unit, muscle defect does not

re-approximate

Arterial injury is quantified as follows:

1. No major vessel disruption

2. Vessel injury without distal ischemia

3. Vessel injury with distal ischemia

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Contamination is quantified as follows:

1. None or minimal contamination

2. Surface contamination (not ground in)

3. Contaminant embedded in bone or deep soft tissues or high-risk environmental

conditions (barnyard, fecal, dirty water, etc)

Bone loss is quantified as follows:

1. None

2. Bone missing or devascularized bone fragments, but still some contact

between proximal and distal fragments

3. Segmental bone loss

To date, relatively few studies have been done comparing the Gustilo-Anderson and

OTA classification systems with regard to prediction of treatment outcomes (eg,

infection, limb amputation, need for soft-tissue coverage, or limb salvage). In a

retrospective study aimed at examining this question, Hao et al found the OTA system

to be better than the Gustilo-Anderson system at predicting postoperative

complications and treatment outcomes in patients with open long-bone

fractures.15 Interobserver reliability appears to be comparable for the two systems. 16

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LABORATORY STUDIES

Laboratory tests are typically not directly important for the acute care of an open

fracture. However, many patients with open fractures will have other injuries that

require appropriate laboratory investigation, and Advanced Trauma Life Support

(ATLS) guidelines should be followed for workup of the traumatized patient. 17

Acute bacterial culture of open fracture wounds, before or shortly after initial

debridement, is of little clinical utility. 18 Organisms isolated in the acute phase of

treatment do not correlate well with clinical infections that result from open fractures.

Therefore, the routine use of cultures at this stage of care is of little benefit to the

patient and is not cost-effective.

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IMAGING STUDIES

Basic orthogonal radiographs (typically, anteroposterior and lateral projections) are

taken of the injured extremity. The images should include the joint proximal and

distal to the area of injury. Oblique images can be used to obtain further information,

as needed. Evaluation of skeletally immature patients is often facilitated by use of

comparison views of the contralateral extremity or joint involved.

Computed tomography (CT) and magnetic resonance imaging (MRI) provide further

detail of bone and soft-tissue injury, but they often are not immediately needed for the

acute management of an open fracture. They tend to be most useful in the

management of complex periarticular injuries.

The use of ultrasonography (US) to assess tissue perfusion, myofascial compartment

pressure monitoring, and perhaps magnetic resonance angiography (MRA) or

enhanced CT imaging of the soft-tissue elements of the extremity are all current areas

of intense research and should provide increased levels of predictive data when

validated.
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APPROACH CONSIDERATIONS

Virtually all open fractures must be considered for operative intervention. The

introduction of bacteria and soft-tissue compromise associated with even “minor”

open fractures mandate appropriate pre-surgical and surgical management to

minimize the risk of clinically important complications.19-20

Perhaps the only absolute contraindication for operative management of an open

fracture arises if the patient is in such critical condition that any operative intervention

could lead to further deterioration; however, there is no evidence from randomized

controlled trials to support this concept.

Even the patient in extremis may benefit from wound irrigation and sterile application

of traction or external fixation in the trauma bay or trauma care unit until a formal

irrigation and debridement can be undertaken in the operating room.

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Special considerations in children

The principles for preoperative and intraoperative management of open fractures in

the pediatric population are similar to those for adults, but there are a few differences

that are largely related to the overall greater healing potential in this population.

In a review article, Stewart et al summarized each aspect of open fracture care for

children.21 They noted that initial evaluation and classification of the injury should

follow the modified Gustilo-Anderson system, as in adults. The primary antibiotic

choices are the same as in the adult population, but the authors cautioned against

alternative regimens involving fluoroquinolones because of issues related to bone

healing and chondropathy in children.

The timing of operative debridement has been studied retrospectively, and the results

have called into question the dogma related to emergency management of open

fractures in this population.22 In one study, no difference in acute infection rate was

found to be associated with operative care within 6 hours after injury as compared

with operative care more than 7 hours after injury.

Further controversy stems from studies related to non-operative management of type I

open fractures,23 but the authors caution strongly against this practice without

definitive study. Soft-tissue care generally follows that used in adults, and the use of

vacuum-assisted closure (VAC) has been shown to be safe and effective in the

pediatric population.24 Fixation choices should account for the greater healing

potential in children and, therefore, often do not require the same degree of stability as

in adults.21
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Special considerations in the elderly

The incidence of open fractures in elderly patients has been shown to be equal or

greater than that in younger patients. In one study, the incidence of open fractures in

women older than 90 years was similar to that in males between the ages of 15 and 19

years.25 This is partially due to longer life expectancies and to bone and skin changes

associated with aging.

Open fractures in elderly patients are most likely to occur in subcutaneous bones (eg,

distal radius, hand, tibia, and ankle), 26 and even low-energy mechanisms can result in

substantial soft-tissue injuries, despite a less severe underlying bony injury.

Furthermore, age has been shown to be a risk factor for infection and wound

complications, nonunion, and even mortality after open fracture. 27-29

Whereas the general principles of open fracture management in elderly patients

remain largely the same, careful evaluation of patient factors such as diabetes,

obesity, smoking status, bone density, and nutrition must be addressed to optimize

patient outcomes. Furthermore, multidisciplinary teams that include medicine or

geriatrics specialties are recommended for operative optimization.

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ANKLE FRACTURES

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint.

Ankle fractures refer to fractures of the distal tibia, distal fibula, talus, and calcaneus.

The true ankle joint contains the tibia (medial wall), fibula (lateral wall), and talus

(the floor upon which the tibia and fibula rest). The true ankle joint allows

dorsiflexion and plantar flexion or the "up and down" movement of the ankle.

The foot can be made to point toward the floor or toward the ceiling via the true ankle

joint. The subtalar joint consists of the talus and the calcaneus. The subtalar joint

allows the foot to be inverted or everted, that is, the sole of the foot can be made to

face inward (inverted) or face outward (everted) through the subtalar joint.

During evaluation of ankle fractures, the mechanism of injury (e.g., eversion,

inversion, dorsiflexion, plantar flexion), associated injuries (e.g., vascular,

ligamentous, capsular), the need for immobilization (e.g., application of a splint), and

the need for referral to a specialist for further treatment or evaluation (e.g., additional

immobilization, surgery, or rehabilitation) are all important components of care.

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PATHOPHYSIOLOGY

The primary motion of the ankle at the true ankle joint (tibiotalar joint) is

plantarflexion and dorsiflexion. Inversion and eversion occur at the subtalar joint.

Excessive inversion stress is the most common cause of ankle injuries for 2 anatomic

reasons. First, the medial malleolus is shorter than the lateral malleolus, allowing the

talus to invert more than evert.

Second, the deltoid ligament stabilizing the medial aspect of the ankle joint offers

stronger support than the thinner lateral ligaments. As a result, the ankle is more

stable and resistant to eversion injury than inversion injury. However, when eversion

injury occurs, there is often substantial damage to bony and ligamentous supporting

structures and loss of joint stability.

Posterior malleolar fractures are usually associated with other fractures and/or

ligamentous disruption. They are commonly associated with fibular fractures and are

often unstable. Transverse malleolar fractures usually represent an avulsion-type

injury. Vertical malleolar fractures result from talar impaction.

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EPIDEMIOLOGY

Of all the ankle injuries evaluated in the ED, only 15% are ankle fractures. The

frequency of ankle fractures has been increasing for the past 20 years, and the rate is

approximately 187 in 100,000 person-years.

Mortality/Morbidity

Patients with unrecognized or undertreated open ankle fractures are at high risk of

infection including local infection, osteomyelitis, and sepsis. Gas gangrene is the most

serious infectious complication. It can be both limb and life threatening.

Vascular supply to the ankle and foot may become compromised by development of a

compartment syndrome or direct injury to blood vessels from bone fragments. Talus

fractures, those commonly occurring in snowboarding trauma, can cause osteoarthritis

and subtalar joint degeneration.

A calcaneal fracture may compromise inversion and eversion of the ankle. Surgical

complications and prolonged rehabilitation are common with calcaneal fractures.

Older patients with ankle fractures experience more long-term complications than

younger patients.
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Age and Sex

The male-to-female ratio for ankle fracture is 2:1. Most patients younger than 50

years are male, while most older than 50 years are female. In children, ankle fractures

have an incidence of 1 in 1000 per year. 30 Pediatric ankle bones are susceptible to

medial malleolar and transitional fractures of the distal tibia. As the population ages,

ankle fractures are becoming more common. An increase in fall risk and osteoporosis

are risk factors.

PROGNOSIS

The prognosis can be improved with prompt, accurate diagnosis and appropriate

treatment and referral. Complex open fractures with substantial soft-tissue damage

have a worse prognosis than isolated closed ankle fractures. Isolated, non-displaced

lateral malleolus fracture, the most common ankle fracture, has a favorable prognosis

and heals unremarkably. Aggressive rehabilitation helps reduce the majority of

morbidity associated with ankle fractures.

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HISTORY

All injured patients should be evaluated for more extensive and serious trauma

depending on the circumstances. Knowledge of the trauma, such as the direction of

torque force applied to the ankle and the foot's position, helps predict the nature and

severity of an ankle injury. Although patients tend to recall the event, they often

cannot depict the exact manner in which their injury occurred.

History of prior trauma to the affected ankle may cause antecedent laxity, instability,

or radiographic abnormalities misinterpreted as an acute event. Chronic medical

condition, such as diabetes, peripheral vascular disease, and metabolic bone disease,

may affect examination findings and treatment plans.

Chronic medication use is an important part of the history and has implications for

management. For example, long-term use of corticosteroids may provoke premature

osteoporosis, whereas non-steroidal anti-inflammatory drugs (NSAIDs) may mitigate

the degree of swelling normally expected with fractures.

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PHYSICAL

Because an ankle fracture often presents with symptoms similar to those of an ankle

sprain, a complete and thorough examination of the involved extremity is needed to

avoid misdiagnosis and prevent unnecessary radiographs.

Indicators suggesting fracture include gross deformity, swelling (especially

perimalleolar), bony tenderness, discoloration, and ecchymosis. Inability to bear

weight on the injured foot also indicates a fracture.

Corroborate any visible deformity by gently manipulating the affected area. Inspect

carefully for the presence of open wounds close to the injured ankle. Assess the

neurovascular status of the foot and ankle. Compare findings to the unaffected

extremity.

 Check presence and quality of pulse of the posterior tibial artery. A hand-held

Doppler can be useful to document arterial patency.

 Check presence and quality of pulse of dorsalis pedis artery. Note that the

dorsalis pedis is congenitally absent in as many as 10-15% of the population.

 Document the time for capillary refill.

Palpate for focal bony tenderness, especially along the medial and lateral malleoli and

posterior aspect of the joint. If possible, palpate the most tender area last. Assess

passive and active range of motion of the ankle joint, noting limitations. During the

immediate acute phase, most patients' ankles are too tender to cooperate with stress

testing of the joint. Examine the ipsilateral knee and foot, particularly documenting

the condition of the proximal fibula and proximal fifth metatarsal.

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CAUSES

Multiple classification schemes are used for ankle fractures. The Lauge-Hansen

system categorizes ankle fractures based on the position of the foot and the forces

acting on it at the time of injury,31 while the Danis-Weber system relies on the level of

fibular fracture. Neither classification scheme has been proven to be prognostic, 32 so

emergency medicine physicians usually label ankle fractures according to the number

of fractures in the ankle (unimalleolar, bimalleolar, trimalleolar).

Danis-Weber classification

These fractures are classified according to location of the fracture and appearance of

the fibular component. To some degree, Weber classification correlates with need for

operative stabilization. Orthopedic surgeons frequently use this classification system:

 Type A depicts a transverse fibular avulsion fracture, occasionally with an

oblique fracture of the medial malleolus. These result from internal rotation

and adduction. These are usually stable fractures.

 Type B describes an oblique fracture of the lateral malleolus with or without

rupture of the tibiofibular syndesmosis and medial injury (either medial

malleolus fracture or deltoid rupture). These result from external rotation.

These may be unstable.33

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 Type C designates a high fibular fracture with rupture of the tibiofibular

ligament and transverse avulsion fracture of the medial malleolus. Usually,

syndesmotic injury is more extensive than in type B. These result from

adduction or abduction with external rotation. These are usually unstable and

require operative repair.

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Pilon fracture

A pilon fracture designates a fracture of the distal tibial metaphysis combined with

disruption of the talar dome. An axial loading mechanism drives the talus into the

tibial plafond (the distal articular surface of the tibia). A common method of trauma is

a foot braced against a floorboard in an auto collision. Skiers coming to an

unexpected sudden stop and victims of free fall from heights also may sustain pilon

fractures. Incidence of pilon fractures ranges from 1-10% of all tibial fractures.

Establish vascular and integument integrity. Pilon fractures are often open. Skin

sloughing is not uncommon. Subsequent edema, fracture blisters, and skin necrosis

from the original injury may convert closed fractures to open injuries.

Depending on the trauma, associated injuries include spinal compression fractures

(especially of L1) and ipsilateral or contralateral fractures of the os calcis, tibial

plateau, pelvis, or acetabulum. As pilon fractures are often comminuted and open,

there is often significant long-term disability.

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Maisonneuve fracture

A Maisonneuve fracture is defined as a proximal fibular fracture coexisting with a

medial malleolar fracture or disruption of the deltoid ligament. Maisonneuve fractures

are associated with partial or complete disruption of the syndesmosis. Treatment of

Maisonneuve fractures depends on stability of the ankle mortise.

Tillaux fracture

A Tillaux fracture describes a Salter-Harris (SH) type III injury of the anterolateral

tibial epiphysis caused by extreme eversion and lateral rotation of the ankle. Incidence

is highest in adolescents, usually those aged 12-14 years, because the fracture occurs

after the medial aspect of the epiphyseal plate of the tibia closes but before the lateral

aspect arrests.34

Distinguish a Tillaux fracture from a triplane fracture. Triplane fracture is a

combination of a SH II and III fracture and is more likely than a Tillaux fracture to

require open reduction and internal fixation.

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Pott fracture

Bimalleolar fractures, termed Pott fractures, involve at least 2 elements of the ankle

ring. These fractures should be considered unstable and require urgent orthopedic

attention.

Cotton fracture

A trimalleolar, or Cotton, fracture involves the medial, lateral, and posterior malleoli.

These fractures are considered unstable and require urgent orthopedic attention.
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Snowboarder's fracture

With the popularity of snowboarding in the late adolescent and young adult

population, it is likely the emergency physician will come across a fracture of the

lateral process of the talus, the so-called snowboarding ankle fracture.35-36

A combination of dorsiflexion and inversion of the ankle produces the lateral talar

fracture. A high index of suspicion should be used in snowboarders who complain of

lateral ankle pain with a normal-appearing ankle radiograph. Computed tomography

imaging is often required to diagnose a talus fracture.

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Hyperplantarflexion variant ankle fracture

The ankle fracture “spur sign” was found to be highly associated with the

hyperplantarflexion variant ankle fracture, as determined by assessment of injury

radiographs. This fracture is composed of a posterior tibial lip fracture with

posterolateral and posteromedial fracture fragments separated by a vertical fracture

line. The spur sign is a double cortical density at the inferomedial tibial metaphysis.

In this study, the incidence of the hyperplantarflexion variant fracture among all ankle

fractures was 6.7% (43/640). The spur sign was present in 79% (34/43) of variant

fractures and absent in all non-variant fractures, conferring a specificity of 100% in

identifying variant fractures. Positive predictive value and negative predictive value

were 100% and 99%, respectively.37

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DIFFERENTIAL DIAGNOSES

 Acute Compartment Syndrome

 Ankle Dislocation in Emergency Medicine

 Ankle Injury, Soft Tissue

 Deep Venous Thrombosis and Thrombophlebitis

 Foot Fracture

 Gout and Pseudogout

 Rheumatoid Arthritis (RA)

 Tibia and Fibula Fracture in the ED

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LABORATORY STUDIES

No laboratory studies are necessary in patients with isolated ankle fracture when

caused by a plausible mechanism. However, repeated ankle fracture or a fracture

caused by simple, low force trauma can require investigation for

osteoporosis, Charcot-Marie-Tooth disease, arthritis, connective tissue disease, or

peripheral vascular disease.

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IMAGING STUDIES

Routinely obtaining radiographs following an ankle injury is not cost-effective

because fewer than 15% of affected patients have fractures. Patients without fractures

are identified reliably from the physical examination. Ottawa ankle rules provide

practical guidelines to select patients for radiographic studies.38-39

Diagnostic guidelines are available from the American College of Radiology

Appropriateness Criteria for suspected ankle fractures. 40 Indications for ankle

radiographs in patients with acute ankle pain include pain in the ankle region plus one

of the following:41

 Bony tenderness at the distal 6 cm of the posterior edge of the medial

malleolus

 Bony tenderness at the distal 6 cm of the posterior edge of the lateral

malleolus

 Inability to bear weight both immediately and in the ED (defined as 4 steps)

 Confounding variables to the Ottawa rules are (1) underlying neurologic

deficit affecting lower limb(s), (2) altered mental status, and (3) multisystem

trauma.

Application of the Ottawa Ankle Rules to patients younger than 18 years is

controversial. While some advocate the rules can be applied to children old enough to

talk and walk, others use the ages 5 or 6 as a cut-off.42

 39

Perform a standard 3-view radiographic examination (anteroposterior [AP], lateral,

and mortise views) of the ankle. In the mortise view, the foot is rotated approximately

15° internally, allowing better visualization of the ankle mortise.

Check radiograph for headset sign (ie, tibia sits atop the talus resembling a headpiece

on a receiver). Normally, the space between the cradle and the handle should be

equal. Lack of symmetry suggests injury.

The ankle joint usually adheres to the ring axiom (eg, a fracture in one part of the ring

often is associated with a second injury). Always look for an associated medial

malleolar fracture when a spiral fracture of the fibula proximal to the ankle mortise is

seen. A vertical fracture of the medial malleolus is also associated with either a lateral

malleolar fracture or rupture of the lateral ligaments.

Accessory ossicles appear frequently adjacent to the medial and lateral malleoli and

may mimic fractures. Clinical correlation is important. Accessory ossicles

demonstrate well-corticated margins, whereas fracture fragments exhibit less-defined

borders.

Radiographic examination of the foot is not required in patients with an isolated ankle

complaint. Although there may be an occult fracture of the base of the fifth

metatarsal, those should be found with adequately performed ankle radiographs. 43

Externally rotated lateral radiographic projection can provide surgeons with additional

information regarding the presence, size, and displacement of posterior malleolar

ankle fractures, according to one study. In this study, posterior malleolar fractures

were accurately identified on 86.67% (26 of 30) of standard lateral radiographs and on

100% (30 of 30) of externally rotated lateral radiographs.

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In addition, surgeons described the fracture with greater precision and had greater

interclass correlation coefficient values regarding sagittal plane displacement (0.977

versus 0.939) and percentage of involvement of the tibial plafond (0.972 versus

0.775) with an externally rotated lateral projection, as compared with a standard

lateral projection.44

ACR Appropriateness Criteria for acute trauma to the ankle includes the following:45

 The use of 3-view (anteroposterior, lateral, and mortise) radiographic

evaluation of patients meeting the criteria of the Ottawa ankle rules.

 Cross-sectional imaging has a limited secondary role primarily as a tool for

preoperative planning and as a problem-solving technique in patients with

persistent symptoms and suspected of having occult fractures.

CT and MRI imaging studies may be part of outpatient management where imaging

features by the other modalities are equivocal. 46

Advanced imaging is most useful to diagnose talar dome and triplane fractures,

distinguish pilon from trimalleolar fractures, and differentiate an accessory ossicle

from an avulsion fracture. Occasionally, these tests are used to assess the complexity

of the fracture and any associated ligamentous and intra-articular injuries.

A bone scan rarely is indicated emergently. It may be useful for diagnosing and

localizing stress fractures, infections, and neoplastic lesions.

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A study of patients who presented to an urban level 1 trauma center with acute ankle

injuries found that the sensitivity of bedside ultrasonography in detecting foot and/or

ankle fractures was 100% and that the specificity of Ottawa Foot and Ankle Rules

increased from 50% to 100% with the addition of ultrasonography. The negative

predictive value was 100%, and the positive predictive value was 100%. 47

OTHER TESTS

Stress radiographs assess the ankle during stress testing; however, results of this test

generally do not affect immediate ED management.

 42

PRE-HOSPITAL CARE

Patients with ankle injuries must be evaluated for further trauma. For an isolated ankle

injury, confirm neurovascular status of the concerned limb, decrease pain, and prevent

further damage.

 Cover open fractures with wet sterile gauze.

 Stabilize the suspected fracture site with a pillow splint, air splint, or bulky

Jones dressing before transporting patient. Try to immobilize the ankle in a

neutral position if possible but avoid excessive handling. Immobilization helps

decrease pain, bleeding, and damage to surrounding soft tissue.

 Pre-hospital reduction of a fracture is not advised unless neurovascular

compromise is evident (e.g., presence of a cool, dusky foot) and a significantly

prolonged transport time is anticipated.

 43

EMERGENCY DEPARTMENT CARE

First, patients should be evaluated for multisystem trauma. Once additional trauma is

excluded, an ankle fracture should be identified as stable or unstable. Unstable

fractures include any fracture-dislocation, any bimalleolar or trimalleolar fracture, or

any lateral malleolar fracture with significant talar shift.

If neurovascular status of the extremity is compromised, the fracture should be

reduced as soon as possible and reduction should be maintained during the healing

period with a cast, external fixator, or open reduction and internal fixation (ORIF).

Open fractures should be guarded from further contamination by covering wounds

with a wet, sterile dressing secured by loosely wrapped dry sterile gauze. Confirm a

current tetanus immunization, administering tetanus immunoglobulin when patients

lack immunity and harbor a grossly contaminated wound.

Consider antibiotic prophylaxis, administering cefazolin for mild to moderately

contaminated wounds and adding an aminoglycoside for highly contaminated

wounds. Administer vancomycin and gentamicin if the patient is allergic to penicillin.

Leave fracture blisters intact. Once ruptured, blisters are more likely to become

contaminated by skin flora.

Unless neurovascular compromise exists, reduction is best deferred to the orthopedic

consultant when an unstable ankle fracture is diagnosed. Closed reduction is

accomplished as follows (refer to Dislocation, Ankle for specific techniques): The

orthopedic consultant typically reduces ankle fractures.

 44

Ankle dislocations are reduced easily, and physicians treating a new fracture should

be skilled in their initial management; however, immediate reduction of a dislocation

may not be required unless blood flow to the foot is compromised. Provide either

local anesthesia with a hematoma block48 or procedural sedation.

Closed reduction is best achieved by manipulating the limb to reverse the direction of

the original deforming forces. For example, a fracture-dislocation resulting from

abductive stress requires pushing the affected site in an adduct direction to restore.

Applying a concurrent distracting force often assists reduction attempts.

Simple, uncomplicated lateral malleolar fractures usually can be splinted in the ED,

followed by arrangement of timely orthopedic follow-up care. Bimalleolar,

trimalleolar, and pilon fractures necessitate urgent orthopedic attention for possible

ORIF.

Oral analgesics should be used liberally as long as they do not interfere with other

medication or the patient's ability to ambulate. The emergency physician might

consider prescribing a narcotic because controversy exists whether NSAIDs impair

fracture and ligament healing.

Admission criteria include open fracture, unstable fracture requiring urgent operative

stabilization, and the presence of or potential for neurovascular compromise (eg

severely comminuted pilon fracture causing a compartment syndrome).

 45

Splinting and casting

Ankle splints are commercially available or may be constructed by sandwiching 10-

12 layers of plaster between 4 sheets of cotton padding.

Posterior splint: Stable injuries can be treated initially with a posterior splint. Ask the

patient to lie prone with the knee bent to a 90-degree angle when applying a posterior

splint. Extend the splint from the metatarsal heads along the posterior surface of the

leg to the level of the fibular head. Maintain the ankle at a 90-degree angle and mold

the splint in the malleolar region.

Sugar tong/short leg stirrup splint: An alternative to the posterior splint is a sugar tong

or short leg stirrup splint. Using 4- or 6-inch plaster, pass the splint under the plantar

aspect of the foot, between the calcaneus and metatarsal heads. Secure in place with

an elastic wrap.49

Splinting of a fracture with bulky padding (eg, Jones dressing) is indicated when

immobilization and compression are needed but swelling is expected to progress. In

very unstable ankle fractures, apply a bivalve cast.

A normal cast is bivalved by cutting completely through the casting material on the

medial and lateral aspects longitudinally to avoid extremity compression. Next, the

bivalved cast is overwrapped with an elastic bandage to stabilize the fracture site,

while still allowing for swelling and expansion.

 46

CONSULTATIONS

Request orthopedic consultation for the following conditions:

 Displaced medial, lateral, or posterior malleolar fracture

 Medial malleolar fracture with lateral ligament damage

 Lateral malleolar fracture with deltoid ligament damage

 Fibula fracture at or proximal to the tibiotalar joint line (e.g., Danis-Weber

classification type C)

 All bimalleolar fractures

 All trimalleolar fractures

 All intra-articular fractures

 All open fractures

 All pilon fractures

Consult a vascular surgeon when vascular flow to the ankle or foot is compromised.

In a fracture with vascular compromise, angiography may be necessary.

 47

MEDICAL CARE

Discharge instructions should include elevation of the affected leg, application of ice,

and non-weight bearing on the injured joint. Ice packs can be applied to areas of

swelling for 10-15 minutes every 3-4 hours while awake for the first 24-48 hours. Ice

works through splints.50-51

Advise patients to refrain from bearing weight on the ankle until seen by orthopedist.

Provide crutches and instructions on their proper use. Ensure proper use of the

crutches before discharge from the ED.

All patients with ankle fractures should receive follow-up instructions for consultation

with a specialist (eg orthopedist, podiatrist). Many fractures, with the exception of

most unimalleolar fractures, will eventually require ORIF.

Patients with gait disorders or other reasons that caused the ankle fracture must be

assessed for a safe discharge to home. The ankle fracture might have a low morbidity,

but concomitant inability to attend to activities of daily living due to conditions, such

as ataxia or peripheral neuropathy, may warrant mobilization of additional support

services or admission.

Provide written and oral information on cast and/or splint care and ensure that the

patient understands which symptoms warrant immediate physician notification and/or

return to the ED.

 48

With increased immobilization, patients are at higher risk for deep vein thrombosis

(DVT). Indications for transferring the patient with an ankle fracture include the

patient's or consultant requests for a transfer and inability of the treating facility to

sufficiently to treat the ankle fracture (eg, requirement for ORIF in facility without

operating room).

Provide adequate stabilization prior to the transport. Discuss the type of

immobilization with the accepting physicians. It may be a simple "pillow" type splint

or more complex sterile dressing and combination posterior and stirrup splint. Be sure

to document the neurovascular status of the leg and foot prior to and following the

immobilization.
 49

COMPLICATIONS

Non-union of the fracture site requires orthopedic referral for operative repair.

Malunion of the fracture site occurs more frequently than nonunion and potentially

proceeds to degenerative changes of the joint. Chronic persistent symptoms such as

pain, weakness, and instability of the ankle may develop. Refer such patients to an

orthopedist for evaluation and possible surgical revision.

Traumatic arthritis complicates 20-40% of ankle fractures. Generally, the more severe

the fracture, the greater the likelihood of posttraumatic arthritis; comminuted pilon

fractures are most at risk. Older patients have an increased risk of arthritic

complications.

Sudeck atrophy, a type of reflex sympathetic dystrophy (RSD), may precede ankle

fractures. Clinical features include complex pain, muscle atrophy, cyanosis, and

edema. The term Sudeck atrophy is reserved for RSD-like conditions accompanied by

a characteristic radiographic appearance (i.e., spotty rarefaction), as opposed to the

ground-glass appearance seen with disuse atrophy of bone.

Osteochondral fractures of the talar surface can easily go unrecognized and if left

untreated may result in chronic pain, locking, and swelling. If suspected, arrange

appropriate orthopedic follow-up care. In children, ankle fractures involving the

growth plate may cause chronic deformity with disturbance of growth of the limb.
 50

GUIDELINES SUMMARY

Ottawa Ankle Rules for Ankle Injury Radiography

An ankle x-ray series is only required if there is any pain in the malleolar zone and

any of these findings:52

 Bone tenderness at the posterior edge or tip of the lateral malleolus

 Bone tenderness at the posterior edge or tip of the medial malleolus

 Inability to take 4 complete steps both immediately and in the ED

A foot x-ray series is only required if there is any pain in the midfoot zone and any of

these findings:

 Bone tenderness at the base of the 5th metatarsal

 Bone tenderness at the navicular

 Inability to take 4 complete steps both immediately and in the ED

Apply the Ottawa Ankle Rules accurately:

 Palpate the entire distal 6 cm of the fibula and tibia

 Do not neglect the importance of medial malleolar tenderness

 Do not use for patients under age 18 years

Clinical judgment should prevail over the rules in the following circumstances:

 If the patient is intoxicated or uncooperative

 If the patient has other distracting painful injuries

 51

 If the patient has diminished sensation in the legs

 If the patient has gross swelling that prevents palpation of malleolar bone

tenderness

Give written instructions and encourage follow-up in 5-7 days if pain and ability to

walk are not better.

 52

OBJECTIVE

To determine the functional outcome (mean modified ankle score of Olerud and

Molander) following open reduction and internal fixation of unstable ankle fracture
 53

OPERATIONAL DEFINITIONS

Functional outcome

It was determined in terms of mean modified ankle score of Olerud and Molander

(Annexure-I).

Each measure comprised nine questions. These are all scores together for a total of

100 points. Higher the score, better is the outcome. It was determined at 3-months

follow up.

Unstable ankle fractures

It was considered if any of following was present:

 Bi-malleolar fracture (If both medial and lateral malleoli are fractured) (as

seen on x-ray of ankle joint, both Anteroposterior and lateral views)

 Tri-malleolar fractures (If both medial and lateral malleoli and distal tibia are

fractured) (as seen on x-ray of ankle joint, both Anteroposterior and lateral

views)

 Fracture dislocations (fractures with >5 mm of medial clear-space

widening) (as seen on x-ray of ankle joint, both Anteroposterior and lateral

views)
 54

MATERIALS AND METHODS

Study Setting:

The study was conducted at Orthopedic Department, CMH Hospital, Lahore.

Duration of Study:

March 20, 2021 to September 20, 2021

Study Design:

Descriptive Case Series

Sampling Technique:

Non-probability consecutive sampling

Sample Size:

Sample size of 60 cases was estimated by using confidence level as 95% with 5%

margin of error and expected mean Olerud and Molander score as 47.55±17.92.8

SAMPLE SELECTION

Inclusion Criteria:

 All patients aged 18-70 years having unstable ankle fracture

 Patients of both gender

 55

Exclusion Criteria:

 Patients with involvement of both sides (X-rays) (as these patients might have

more disability and poor outcome score)

 Patients having any congenital anomalies of lower limb (Medical records) as

these patients might have more disability and poor outcome score)

 Patients with previous history of fracture to any bone to same lower limb

(Medical records) as these patients might have more disability and poor

outcome score)
 56

DATA COLLECTION PROCEDURE

Approval from Ethical Review Board of the hospital was obtained. Total 60 patients

unstable ankle fractures were enrolled in the study. Written informed consent for

inclusion into this study was obtained. Patients presenting in Outdoor Department

with unstable ankle fractures were included and demographic details including age,

gender, side of injury, duration since injury, body mass index (BMI) were noted.

They underwent open reduction and internal fixation as per standard method.

Following surgery, they were provided care as per departmental protocols. At 12

weeks follow up, they were assessed for modified ankle score of Olerud and

Molander by the same surgical team. All data were recorded on the proforma

(attached).
 57

DATA ANALYSIS PROCEDURE

The collected data were entered and analyzed accordingly using SPSS v25.0. Mean ±

SD were calculated for age, duration since injury, BMI and modified ankle score of

Olerud and Molander. Frequency and percentages were calculated for gender and side

of injury. Final outcome (mean modified ankle score of Olerud and Molander) was

stratified for age, gender, side of injury, duration since injury and BMI. Post-

stratification, Student’s t-test was applied. A p-value ≤0.05 was considered as

significant.
 58

RESULTS

Total 60 patients with unstable ankle fracture were selected for this study. Mean age

of patients was 43.80±15.55 year. There were 42(70.0%) male and 18(30.0%) female

patients.

According to age distribution, 13(21.7%) were in 18-30 years age group, while

18(30.0%) and 29(48.3%) were in 31-45 years and ≥46 years age group respectively.

According to body mass index distribution, 37(61.7%) had normal weight, while

19(31.7%) and 4(6.6%) were overweight and obese respectively.

According to side of injury distribution, 22(36.7%) had injury on right ankle and

38(63.3%) had on left ankle.

According to duration since injury distribution, 45(75.0%) had duration since injury

for <6 months and 15(25.0%) had for ≥6 months.

Mean modified Olerud and Molander ankle score among patients with unstable ankle

fracture after 3 months of open reduction and internal fixation was 79.67±9.15.
 59

Table-1: Frequency distribution of gender

Gender Frequency Percent

Male 42 70.0

Female 18 30.0

Total 60 100.0
 60

Table-2: Frequency distribution of age groups

Age groups Frequency Percent

18-30 years 13 21.7

31-45 years 18 30.0

≥46 years 29 48.3

Total 60 100.0
 61

Table-3: Frequency distribution of body mass index

Body mass index Frequency Percent

Normal 37 61.7

Overweight 19 31.7

Obese 4 6.6

Total 60 100.0
 62

Table-4: Frequency distribution of side of injury

Side of injury Frequency Percent

Right 22 36.7

Left 38 63.3

Total 60 100.0
 63

Table-5: Frequency distribution of duration since injury

Duration since injury Frequency Percent

<6 months 45 75.0

≥6 months 15 25.0

Total 60 100.0
 64

Table-6: Mean modified Olerud and Molander ankle score

Std. Minimum
n Mean Maximum
Mean Deviation score
score
modified
Olerud and
Molander
ankle score 95
60 79.67 9.15 65
 65

Table-7: Stratification of modified Olerud and Molander ankle score with

respect to gender

Std.
Mean Gender n Mean p-value
Deviation
modified
Olerud and
Molander Male 42 80.83 9.49
ankle score 0.133
Female 18 76.94 7.89
 66

Table-8: Stratification of modified Olerud and Molander ankle score with

respect to age groups

Std.
Age groups n Mean p-value
Deviation
Mean
modified
18-30 years 13 84.23 10.96
Olerud and
Molander
ankle score 31-45 years 18 78.89 6.98 0.121

≥46 years 29 78.10 9.10

 67

Table-9: Stratification of modified Olerud and Molander ankle score with

respect to body mass index

Body mass Std.

n Mean p-value
index Deviation
Mean
modified
Normal 37 79.32 9.22
Olerud and
Molander
ankle score Overweight 19 81.84 9.16 0.168

Obese 4 72.50 5.00

 68

Table-10: Stratification of modified Olerud and Molander ankle score with

respect to side of injury

Side of Std.
Mean n Mean p-value
injury Deviation
modified
Olerud and
Molander Right 22 79.32 8.90
ankle score 0.825
Left 38 79.87 9.40
 69

Table-11: Stratification of modified Olerud and Molander ankle score with

respect to duration since injury

Duration Std.
Mean n Mean p-value
since injury Deviation
modified
Olerud and
Molander <1 year 45 79.56 9.46
ankle score 0.872
≥1 year 15 80.00 8.45
 70

DISCUSSION

The ankle is a composite joint. It consists of two dissimilar articulations: syndesmosis

connecting the distal end of crural bones and diarthrosis between their ends and talus.

The ankle is a mortise in which the talus is constrained by the fibula laterally and tibia

both superiorly and medially, this configuration as also been referred to as the

malleolar fork.53 The ankle and foot segments provide a stable but mobile support

needed to maintain an upright posture.

The movement at subtalar joint and ankle joint are usually supportive to each other.

Normal motion of the ankle joint is predominantly in the sagittal plane, but it involves

variable degrees of rotation around the vertical and longitudinal axes. Inman

described the empirical axis of the ankle joint as passing approximately 5 mm distal to

the tip of the medial malleolus and 3 mm distal and 8 mm anterior to the lateral

malleolus.54

The empirical axis of ankle joint is also described as the one passing just below the

tips of the medial and lateral malleolus. Because of the variable contours of the

medial and lateral talar dome trochlea, ankle joint has a continuously changing axis of

rotation.55 The major weight-bearing surface of ankle is the tibia - talar surface. One

sixth of static load of the body weight is transferred through fibula. The fit of talus in

mortise in precise, making it the most congruent of the weight bearing joints.
 71

This loading actually serves as a stabilizing influence on the joint because it causes

the talus to seek an anatomically reduced position underneath the tibial plafond (by

means of an associated 2 mm lateral talar shift). The contributions of the articular

surfaces, the ligaments, and the capsular and musculotendinous structures, to the

stability and function of the ankle are influenced by changes in loading characteristics

and joint position and are altered in response to injury.

The ankle fractures occur as a result of strong rotational or predominantly axial

Loading. The malleolar fractures are caused predominantly by rotational forces

whereas axial loading causes tibial plafond fractures, predominantly. The malleolar

fractures primarily involve lateral or medial malleolus and often other parts of the

ankle as well. Sharing and tensile forces apposed through the talus produce them

indirectly.

Most malleolar fractures occur when the part, including the talus, is fixed on the

ground by the body’s weight. The type of malleolar fracture that occur depends on

two factors: the position of the foot at the time of injury, either supination or

pronation, and the deforming force, which are external rotation, abduction or

adduction.

A relative bending moment is produced with rotation either in the coronal plane,

producing talar adduction or abduction relative to tibia, or transverse plane, causing

relative internal rotation of the tibia on the talus. These injuries are referred to as

external rotation injuries. The initial position of the foot is important because it

determines which structures are tight and therefore are most likely to be injured first.

When the foot is pronated, the deltoid ligament is tense, and the initial injury is

medial, either a medial malleolar fracture or a deltoid ligament disruption.

 72

The structures that are damaged are, in order, the anterior tibiofibular ligament (stage

1), the lateral malleolus (stage 2), the posterolateral aspect of the capsule or the

posterior malleolus (stage 3), and the medial malleolus or the deltoid ligament (stage

4). A fracture of the posterior malleolus can occur in association with either external

rotation or abduction injuries of the ankle.

A classification system is useful only if it assists in the selection of the appropriate

management, offers a prognosis of eventual outcome, or allows comparison of the

results of treating similar injuries. Several different classification systems of ankle

injuries exists, but those in current use are Anatomical types, Lauge – Hansen’s

system, Danis-Weber system and the AO/ Orthopaedic Trauma Association

(AO/OTA) system. In the present study, Danis-Weber system classification system

was used for operative evaluation.

Burwell and Charnley showed that anatomical reduction and rigid fixation led to early

return to function. The results in current study were compared with that of Burnwell

& Charnley.56 Gregory Joy et al57 study recommended that anatomical reduction is the

key towards a good clinical outcome, our study is also in contention with the same.

Most authors have stated that anatomical reduction of displaced medial malleolus

ensures correction of talar displacement and is of paramount importance in treating

unstable fractures.58 However, Heller et al59 states that talus is more accurately

repositioned in mortise by anatomical reduction of lateral malleolus.

 73

Observations in our study support the contention of Heller et al59 that lateral malleolus

is the key to the anatomical reduction of malleolar fractures, because the displacement

of the talus faithfully followed that of the lateral malleolus. Poor reduction of the

lateral malleolus fracture would result in persistent lateral displacement or residual

shortening.

Hughes et al60 in their study recommended that lateral malleolus should be fixed first,

then medial malleolus is inspected for stability and fixed if necessary. This allows

minimal postoperative immobilization and rapid recovery of function. This does not

necessarily lessen the importance of medial malleolus, because the fractures of the

medial malleolus close to the plafond do require more anatomic reduction to restore

normal Tibio-Talar relationship but it does serve to emphasize that the lateral

malleolus should no longer be ignored.

Bistrom et al61 in their study stated that the type of the fracture did not dictate the

outcome of their study, the same was applicable in our study as well. Therefore our

study supports the view of Klosser et al. 62 according to which reduction determines

the final clinical result irrespective of the type of fracture.

In many studies it was seen that the syndesmosis is stable after reduction and internal

fixation of fibula fracture and medial malleolar fracture. In the current series, two

patients underwent trans-syndesmotic screw fixation. Excellent outcomes were seen

in both the patients.

 74

Winkler et. Al63 showed the use of fixation of the antiglide plate in the fixation of

lateral malleolus in case of type B Weber fractures. The study showed the construct to

be bio-mechanically sound. The use of this technique is being recommended

especially in the osteoporotic bones which were found to stand true in our series

where 12 osteoporotic patients were treated with plating and had good functional

outcomes.

Ramasamy P et al64 performed fibular nailing in 11 Weber B ankle fracture in elderly

patients (67.2 years) with osteoporotic bones between March 1996 and February

2000. All the fractures were displaced with significant talar shift. Nine patients

remained under follow-up (average 25.9 months). Results were good and excellent in

88% of cases by the modified olerod and molander scoring system.

Burwell and Charnley65 advocated postoperative joint mobility exercises in bed until

motion was restored followed by full weight bearing in a cast. Kristensen et al66 either

used no cast or applied one for a few days postoperatively and then allowed full joint

mobilization out of the cast. They advocated the use of crutches to maintain a non-

weight bearing status.

Meyer and Kumler67 used a post-operative cast but only for an average of 3.8 weeks

followed by non- weight bearing mobilization until fracture union. Thus in various

studies comparing the effect of early movement compared to immobilization and

weight bearing versus non-weight bearing, the conclusion is that there is no difference

in the final result whichever regime is used. 68

 75

In this study, Mean modified Olerud and Molander ankle score among patients with

unstable ankle fracture after 3 months of open reduction and internal fixation was

79.67±9.15. In a previous study, outcome was determined using mean modified ankle

score of Olerud and Molander and it was 47.55±17.92 at 3 months follow up.8 Ankle

fractures in older people are increasing in number as the population ages Although

ankle fractures like all other lower limb fractures pose a serious illness and have high

impact over quality of life of the patients.

 76

CONCLUSION

Operative treatment for ankle fractures results in good functional outcome post-

operatively. Anatomical reduction of the fracture is associated with better functional

outcome. Early treatment without delay, anatomic reduction and fracture fixation,

stringent post-operative mobilization and rehabilitation should help improve outcome

in an operated ankle fracture.

 77

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PROFORMA

FUNCTIONAL OUTCOME FOLLOWING OPEN REDUCTION

AND INTERNAL FIXATION OF UNSTABLE ANKLE

FRACTURE

Patient’s Name: _______________________________________________________

Date: ___________ Hosp. Reg.#: _____________ Phone #: ____________________

Address: _____________________________________________________________

Age: _____________ (years)

Gender: Male Female

Side of injury: Right Left

Duration since injury: _____________

BMI: ___________ (kg/m2)

Modified Olerud and Molander ankle score: ___________________

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Annexure-II

MODIFIED OLERUD AND MOLANDER ANKLE SCORE

 Pain was assessed using Visual Analog scale. Patients were asked to report

their pain as per VAS scale and it was recorded. It was considered “Yes”, if

VAS is >5.
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 Functional scale questions were asked from all patients by the investigator and

their responses were recorded.