Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

Case Conclusion:
Displaced Ankle Fracture in 61-y/o
Diabetic Female

In a recent Residency Insight we reviewed the clinical exam, physical and imaging findings, of this complicated patient with a displaced, fractured ankle. There have been a few excellent responses in the eTalk on this topic and I encourage each of you to continue to share your thoughts and perspectives on this, or any other topic.

Course of Care:

Considering the delay in presentation to the Emergency Department and the significant swelling that the patient demonstrated upon presentation, the patient was closed reduced by the emergency department staff and placed into a compressive dressing with a posterior splint; however the patient continued to complain of significant pain in the extremity despite her general peripheral neuropathy and this stabilization.   Subsequent radiographs demonstrated persistent instability at the fracture site and attempts were made to further stabilize the fracture via a modified Robert-Jones compression dressing to address the persistent swelling and to allow for appropriate preoperative work-up and medical clearance. 

Fig. 1 Click for larger view

The patient continued to demonstrate significant instability and persistent despite being placed into the splint – even to the point of further subluxation. (Fig 1)

The splint was removed to evaluate the patient’s increased pain complaint, and a superficial ulceration was noted to have formed along the area just proximal to the medial malleolus where the tissue had been compromised during the dislocation. (Fig. 2)

Figure 2: A medially based ulceration was noted on the first day following the patient’s fall. Its location occurred in an zone of tissue compromised during the patient’s ankle dislocation.

Considering the development of this ulceration, and the morbidity and mortality associated with lower extremity ulcerations in patients with diabetes, the decision was made to pursue more aggressive options with regard to the management of this fracture. And once appropriate medical clearance had been obtained—approximately 24 hours after the initial injury—the decision was made to bring the patient to the operating room to further stabilize her right trimalleolar fracture/disclocation. Considering the patient’s comorbidities, degree of swelling, and clinical presentation of the fracture pattern and the medial ulceration, the decision was made to stabilize this fracture utilizing external fixation.

For this application, a circular, Orthofix TrueLok® fixation System was utilized to provide appropriate fracture fragment reduction and stabilization.  In the operating room prior to external fixators placement, the ankle remained thoroughly unstable. (Fig. 3)

Figure 3: Upon Removal of the splint, the patient's ankle displaced again with minimal effort suggesting significant overall instability.

The use of external fixation in this application allowed for complete reduction of the fracture without making any incisions in the extremity –thus reducing the overall risk for dehiscence and other wound healing complications. Once the proximal ring component had been secured in place utilizing skinny wires in the neurovascular safe zones, a combination of smooth and olive wires were utilized to stabilize the foot within the foot ring.  Once these were tensioned appropriately, the telescoping, articulating rods between the stable proximal component and the footplate were loosened to allow for distraction at the fracture site.  The ankle was distracted within the frame and reduction of the fracture fragments were observed under fluoroscopy.  The articulating, telescoping rods were then locked to maintain the appropriate level of distraction, and the fracture fragments were further stabilized utilizing olive wires. (Fig. 4)

Figure 4: A combination of smooth and olive wires were utilized to stabilize the medial and lateral malleolar fracture fragments.

Each pin-site was then dressed with a silver-impregnanted AMF-AG antimicrobial dressing, a 2x2 gauze (Fig. 5) and an ace wrap was placed to provide edema control. (Fig. 6).

Figure 5: Following ring placement, the pin-sites were dressed with a silver impregnated antimicrobial dressing to wick away drainage and reduce the risk of pin-site infection.

Figure 6: An ace wrap was placed to provide for edema control in the post-operative phase.

Considering the patient’s previous history of charcot neuroarthropathy in the contralateral limb, and her apparent osteoporosis, the decision was made to place a PEMF bone stimulator on this patient to further stimulate osseous healing at the fracture sites.

The patient tolerated the procedure well and was discharged on post-op day 1 with home healthcare to provide in-home physical therapy and daily pin-site care. While it would be ideal to keep this patient non-weight bearing, considering the deformity on her contralateral foot, the use of external fixation will allow this patient limited weight bearing on the affected extremity throughout the duration of her healing.

Discussion

This was a challenging case for a number of reasons.  Certainly, these types of fractures are complex and can be fixated in a variety of ways.  External fixation was selected in this instance because it allowed for rapid, rigid reduction of the fracture with relatively little risk for tissue envelope complications, and it would allow the patient the opportunity for limited weight bearing (for transfers, etc) in the post operative phase to reduce the risk of breakdown on the contralateral charcot foot.

Medical management in these complex patients is vital—as many readers pointed out in the etalk section—and it is important that a thorough workup be performed prior to surgical intervention.  In this particular instance, the patient’s vitamin D level was noted to be significantly low, and she was started on a booster course of Vitamin D pre-operatively which was continued post-operatively to further promote bone health in this challenging patient.

Now that we've reached the conclusion of this case, please feel free to share any additional thoughts or comments you may have in the eTalk string on this presentation.

I Look forward to hearing from you! And I encourage each of you to share your thoughts, perils, and experiences in the eTalk section of Present Podiatry. We all grow from the shared knowledge of our online community!

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