Skip to main content

Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study

Abstract

Background

To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries.

Methods

All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed.

Results

In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p < 0.001). Posterior malleolus fragment (PMF) size predicted LOR with ≥ 22.5% being the threshold for critical PMF-size (p < 0.001).

Conclusion

Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size.

Trial registration

The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Peer Review reports

Background

Ankle fractures are among the most common fractures in adults with an incidence currently given as 71 – 200 per 100,000 person-years [1,2,3,4,5,6,7,8]. The incidence of these fractures have substantially risen over the last decades, in particular among elderly women who demonstrate more complex fracture patterns compared with other demographic groups [4, 5, 7, 9, 10]. Between 11 to 64% of all ankle fractures are classified as moderately to severely dislocated [2, 11,12,13], with fracture-dislocation and complex fracture patterns (i.e. bi- and trimalleolar fractures) demonstrating worse clinical outcomes compared with simple fractures [14, 15].

Open reduction and internal fixation (ORIF) is considered the mainstay of treatment for unstable malleolar fractures [6, 7, 10,11,12,13, 16,17,18,19,20,21,22,23,24]. Although immediate ORIF is recommended in the acute setting [7, 25], concomitant soft-tissue injuries can compromise long-term clinical outcome due to the increased risk of complications [18, 19]. To reduce the risk of soft-tissue problems, immediate reduction is mandatory while ORIF can be postponed until the swelling has subsided and the soft-tissues have consolidated [10, 16, 21, 26, 27]. Whereas fracture-dislocations with critical compromised soft-tissues (e.g., compartment syndrome, open fractures, skin blisters) are generally managed with an ankle-spanning external fixator (ex-fix) [28], the type of temporary fixation in those fracture-dislocation cases, in which the ideal time window for early ORIF has been missed and/or moderate to severe soft-tissue injury prohibit immediate ORIF is more open to debate. Besides ex-fix, also temporary immobilization in a splint or cast has been proposed as an alternative.

An ex-fix achieves reduction and stable fixation through axial traction and the resulting ligamentotaxis. Apart from the risk of pin tract infection, this type of fixation necessitates a staged additional surgery [29]. While a cast can provide a sufficient retention in a non-invasive manner, the retention is achieved by external pressure which carries the risk of additional soft-tissue damage and makes soft-tissue monitoring more difficult. With subsiding edema and decreasing swelling, the fit of the cast is reduced with the subsequent risk of losing the reduction over time [13, 23].

Given the limited evidence on the use of a temporizing cast, we sought to determine whether and for whom a cast immobilization is a safe alternative to temporary ex-fix in closed ankle fracture-dislocations. The aim of this study was to compare the short-term outcomes between ex-fix and plaster cast immobilization. Additionally, it was attempted to identify predictors for loss of reduction. It was hypothesized that both methods can achieve comparable short-term outcomes in those fracture-dislocation cases in which ORIF was delayed and/or moderate to severe soft-tissue injury prohibited immediate ORIF. The primary outcome were short-term soft-tissue-related complications. Secondary outcomes included loss of reduction, conversion to ex-fix, time to surgery and time to discharge.

Methods

Patient selection

The institutional database of our level-1 trauma center was analysed retrospectively for all patients with ankle dislocation-fractures treated surgically between 2007 and 2017. All skeletally mature patients with an ankle dislocation-fracture as a mono-trauma and a minimum 6-months follow-up were included. Skeletally mature was defined by a closed epiphysis on ap and lateral X-rays. Ankle dislocation-fractures was defined as ≥ 50% subluxation of the talus relative to the tibia in one of both planes on the X-ray or when a joint reduction maneuver was successfully performed before the X-ray was taken [30]. Excluded were those with incomplete records, open fractures, immediate definitive ORIF or treated nonoperatively.

Demographics and outcomes

All records of the eligible patients were reviewed to determine baseline demographics (age, gender, smoking, height, weight, BMI), comorbidities (diabetes, steroid use, anticoagulation use, ASA-score), injury description (side, fracture classification), treatment history (primary ex-fix, cast type, loss of reduction, conversion of treatment, time to conversion, time to surgery, time to discharge) and the evaluation of complications encountered during follow-up. Loss of reduction was defined by an incongruent tibiotalar joint with a dislocation of ≥ 5 mm in one of both planes on the X-ray. All fractures were classified independently by two of the authors using the Arbeitsgemeinschaft für Osteosynthesefrage/Orthopaedic Trauma Association (AO/OTA) classification system based on the available imaging (R.G. and P.P.) [31]. Although this classification system has a high interobserver reliability [32], a consensus between observers was made in case of doubt. Measurements were acquired at the level of the epiphyseal scar on the lateral radiographs. The ratio between the width of the posterior malleolar fragment and the tibial width defined the posterior malleolar fragment size (Fig. 1). Surgical site infections (SSI) were defined according the criteria of the Centers for Disease Control and Prevention (CDC) [18, 19, 33]. A superficial SSI (sSSI) was defined as requiring only antibiotics whereas a deep SSI (dSSI) needed revision surgery. Complex regional pain syndrome I (CRPS-I) was defined using the Modified (Budapest) International Association for the Study of Pain Criteria [34].

Fig. 1
figure 1

A Anteroposterior and lateral radiograph of a reduced trimalleolar ankle fracture-dislocation temporized in a plaster cast. Measurements were acquired at the level of the epiphyseal scar. The ratio between the width of the posterior malleolar fragment (PM) and the tibial width (TW) defined the posterior malleolar fragment size. In the presented case, the posterior malleolar fragment size was 27%. B Subsequent radiographs demonstrated a loss of reduction

Treatment

Immediate closed fracture reduction was performed as an emergency procedure. It was aimed to perform ORIF within 6-8 h from the time of injury. If immediate surgery was not possible, ORIF was postponed until the soft-tissue had recovered. First, it was tried to retain the reduction with a below-the-knee univalved fiberglass cast or plaster of Paris slab along with plaster of Paris stirrup. If there was insufficient reduction in the subsequent X-ray, an ex-fix was applied. In the case of secondary dislocation, a further attempt with closed reduction was made. If unsuccessful or a re-dislocation occurred, conversion to ex-fix was indicated. Moreover, conversion to ex-fix was indicated when the soft-tissue envelope was compromised by fracture blisters or skin necrosis. Ankle-spanning ex-fix was performed using two half-pins in the tibial shaft and one calcaneal Steinmann pin to create a delta frame. Both patients with ex-fix and patients with a cast immobilization were hospitalized for monitoring and decongestive measures. All surgeries were performed by a board-certified trauma surgeon or by residents under the supervision of the attending trauma surgeon according to the AO/OTA principles [35].

After definitive ORIF, the ankle was immobilized in a neutral position in a walker or a cast with limited weight-bearing using crutches. Early mobilization was performed out of the walker/cast instructed by a physiotherapist. These restrictions were recommended for 6 – 12 weeks. Low molecular heparin was routinely administered for thromboembolic prophylaxis. Routine points in time for clinical and radiographic evaluation were set at 6, 12, 24 and 52 weeks.

Statistical analysis

The data were analysed using R (R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL http://www.R-project.org/). For numerical data, the Welch two-sample t-test was used. For categorical data, Pearson's Chi-squared test and Fisher´s exact tests were used, as appropriate. Multiple regression analyses determined predictors of loss of reduction. Predictors were further analysed with a receiver operating characteristic (ROC) curve analysis and Youden index analysis to determine a threshold. Differences were considered to be statistically significant when p ≤ 0.05. A post-hoc power analysis was completed based on the incidence rates in case statistical significance was lacking.

Results

A consecutive series of 310 patients with 313 ankle fracture-dislocations met the inclusion criteria. A total of 151 cases were excluded, resulting in a study cohort of 160 patients with 162 ankle fracture-dislocations (Fig. 2). The cohort included 68 men and 94 women with a mean age of 50 years (range 20 to 87 years). Bimalleolar fractures occurred in 29.6% and trimalleolar fractures accounted in 70.4% of the cases. A lateral malleolar fracture type Danis-Weber B was seen in the majority of cases (74%) (Table 1). A posterior malleolar fracture was present in 53.1% of the cases.

Fig. 2
figure 2

Flow chart of inclusion in the final external fixator (Ex-fix) group or plaster cast group

Table 1 AO/OTA classification N (%)

Of the 162 fracture-dislocations, primary ex-fix was performed in 35 cases and 127 cases had a cast immobilization (mean age 50 years, 61 female). Of the latter, a total of 95 cases (74.8%) were immobilized with a fiberglass cast. A loss of reduction after temporizing cast was observed in 25 cases (19.7%) within a mean of 3 days (0–11 days): 17 of these cases were converted to ex-fix (13.3%); 7 cases were re-reduced in a cast (5.5%); in 1 case the dislocation was accepted and no action was required (0.8%). Another 2 cases were converted from temporizing cast immobilization to ex-fix because of a compromised soft-tissue envelope. Thus, 19 cases were converted to ex-fix (15.0%), resulting in 54 cases in the ex-fix group and 108 in the cast group (Fig. 2).

Baseline characteristics were comparable between ex-fix and cast group for the majority of variables (Table 2). Right side, smoking and osteoporosis skewed towards the ex-fix group (p < 0.047). No difference in fracture type was found between the ex-fix and the plaster cast group (p = 0.068). Ex-fix-cases underwent definite ORIF on average 2.7 days later and were hospitalized on average 5.0 days longer when compared to patients with temporizing cast immobilization (p < 0.001) (Table 3).

Table 2 Baseline Characteristics
Table 3 Results

At least one complication was seen in 41 patients (25.3%). Soft-tissue complications were seen in 22 patients (13.6%) with 11 (6.8%) patients having a SSI and 11 (6.8%) presenting skin necrosis. CRPS was diagnosed in 8 patients (4.9%) (Table 3 & 4). The rate for SSI and skin necrosis did not differ significantly between ex-fix and cast immobilization (p = 0.122 and p = 0.825). A tendency toward a lower CRPS-I-rate was seen in favor of the cast group (p = 0.073). A post-hoc power analysis showed a needed sample size of 536, 25064 and 420 patients to detect a difference in the rate of SSI, skin necrosis and CRPS-I, respectively, using a 95% confidence interval and a power of 80%.

Table 4 .

Multiple regression analyses revealed posterior malleolar fragment size as an independent risk factor for loss of reduction after cast immobilization (p < 0.001), whereas age, gender, side, BMI, co-morbidities, osteoporosis, fracture classification, the presence of a posterior malleolar fragment and cast type were not associated with re-dislocation (p > 0.085). ROC-analysis of posterior malleolar fragment size resulted in an area under the curve of 0.766 (p < 0.001) (Fig. 3).

Fig. 3
figure 3

Receiver operating characteristic (ROC) curve analysis demonstrated an area under the curve of 0.766 (p < 0.001) and identified two thresholds for posterior malleolar fragment size to predict loss of reduction in a cast with the same tradeoff between sensitivity and specificity. A threshold of 13.5% (A) resulted in a sensitivity of 83% and a specificity of 57%. A threshold of 22.5% (B) was associated with a sensitivity of 61% and a specificity of 79%

Discussion

The findings of this study demonstrate that within the presented cohort, a temporizing cast immobilization was associated with no worse results compared to ex-fix. A trend toward a less favorable rate of soft-tissue-related complications was seen for ex-fix. Those patients temporized with a cast underwent definite fixation earlier than the patients with ex-fix, which resulted in a shorter length of stay. An important finding of this study was that posterior malleolar fragment size was the sole predictor of loss of reduction of all assessed variables. Therefore, casting of patients with a critical posterior malleolar fragment size must be discussed.

Soft-tissue problems associated with temporizing cast immobilization were comparable with the rates reported by other authors with SSI ranging between 1 to 20% and skin necrosis rate ranging between 4.9 to 8.9% [6, 12, 17, 24, 25, 29, 30]. Wawrose et al. compared 28 patients with temporizing plaster splint immobilization to 28 patients with ex-fix following ankle fracture dislocation [30]. The authors found that splint immobilization was associated with a high skin necrosis rate of 17.8% when compared to a temporizing ex-fix which yielded 0% skin necrosis. The rather high necrosis rate of 17.8% and sSSI rate of 17.8% in the splint group and the absence of complications in the ex-fix group favorized the use of ex-fix as a temporizing fixation following ankle dislocation fractures. These remarkably good results following ex-fix could not be reproduced at our institution; yet, our necrosis rate within the cast group was substantially less. These differences between this study and our study might be a result of the high re-dislocation rate of 50% in the splint group seen by Wawrose et al.

Loss of reduction was contributed to the type of cast in the study by Baker et al. [36]. A 50% (11/22 cases) loss of reduction was noticed when temporizing immobilization was performed with a plaster splint, whereas no re-dislocation was seen in the bivalved fiberglass cast group (0/17). In our study, the type of cast was not a predictor for loss of reduction. Only size of the posterior malleolar fragment was highly associated with loss of reduction. Although size of the posterior malleolar fragment does not correlate with clinical and radiological outcomes after ORIF [37], our findings support the idea that the posterior malleolus is an important indicator for fracture stability of the ankle. Given this result, the substantial difference between our moderate re-dislocation rate of 19.8% within the cast group and an unacceptable high re-dislocation rate of 50% reported by Wawrose et al. might be attributed to differences in posterior malleolar fragment sizes between the study groups [30]. It must be noted that, in contrast to our study, patients included in the study by Wawrose et al. were discharged after splinting, which makes strict monitoring of the ankle and a prompt reaction to soft-tissue problems difficult. Moreover, the lack of control of patients’ behavior at home might lead to noncompliance with patients walking on the cast.

As stated by Mittlmeier et al., it remains a question of definition to distinguish fractures of the posterior pilon from ankle (luxation) fractures [38]. According to the classification of Bartonícek and Rammelt, type 1 and 2 fractures are caused by a combination of tensile, compressive, and shear forces and thus are most likely to result from capsulo-ligamentous bony avulsion mechanisms whereas type 3 and 4 fractures with a large articular component show morphologic overlap with partial pilon fractures [39, 40]. This is consistent with the observations of other authors [41] without a clear consensus regarding delineation [42].

In another retrospective study Buyukkuscu et al. showed a higher rate of reduction loss and skin necrosis in the splint group (n = 69) compared to the external fixator group (n = 48) [43]. The time to surgery was shorter in the external fixator group. This difference may be explained by inclusion of patients with poor soft tissue conditions only.

Regarding predictors, a ROC-analysis identified two thresholds for posterior malleolar fragment size to predict loss of reduction in a cast demonstrating the same tradeoff between sensitivity and specificity (Fig. 3). Whereas a 13.5% threshold would overcome a re-dislocation in a temporizing cast in the majority of cases, a substantial percentage of patients would be treated with an additional surgery that was not necessary due to the false-positive rate associated with a specificity of 57%. Since our results regarding complications with cast immobilization were promising, we prefer a more conservative approach. Therefore, the 22.5% threshold, which allows for some degree of re-dislocation but overcomes surgical overtreatment, was preferred as a cutoff for critical posterior malleolar fragment size to define ankle fracture-dislocations in which a primary temporizing ex-fix seems appropriate.

Our study is limited by its retrospective nature. The slightly skewed distribution between groups and the limited power are exemplary for this. The latter highlights the challenges associated with a monocentric study, even in a level-1 trauma center, in which small differences in complication rates are seen, needing a larger sample size to provide a sufficient power. Patients were treated by several surgeons, since this retrospective analysis covered 10 years of treatment in a teaching hospital. At the time, no clear indication to do a primary ex-fix was defined and depended on surgeon´s decision-making. This imposes a further selection bias of the study cohort. This bias in selecting patients for primary external fixation may partly explain why a difference of 5 days in average hospital stay was found between the 2 groups. Because of the multiple variables that were needed for the analyses, a substantial number of cases had to be excluded due to incomplete data. A prospective assessment would have increased the sample size by assessing those variables in a standardized fashion. The short-term follow-up of a minimum of 6 months prohibited us to make any conclusions on long-term outcomes on the initial use of a cast versus ex-fix for ankle fracture-dislocation management. Although the majority of cases underwent a CT scan of the ankle, the size of the posterior malleolar fragment was only assessed on lateral radiographs. This measurement might be influenced by malrotated views, as commonly seen in the acute setting. Yet, radiographs are the primary images acquired in the acute assessment of an ankle fracture and hence makes the results of this study more applicable for quick decision making.

Conclusions

Temporizing cast immobilization was a safe and viable option for those ankle fracture-dislocations in which early ORIF was not possible. Those temporized with a cast underwent definite fixation earlier than the patients with ex-fix, which resulted in a shorter length of stay. Posterior malleolar fragment size was an important predictor for loss of reduction in a cast, with 22.5% being identified as the cutoff for critical posterior fragment size. Therefore, a primary temporizing ex-fix in those patients with a posterior malleolar fragment approximating one fourth of the distal tibial articular surface seems appropriate.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AO/OTA:

Arbeitsgemeinschaft für Osteosynthesefrage/Orthopaedic Trauma Association

ASA:

American Society of Anesthesiologists

BMI:

Body Mass Index

CDC:

Centers for Disease Control and Prevention

CRPS-I:

Complex regional pain syndrome I

dSSI:

Deep surgical site infections

Ex-fix:

External fixator

LOR:

Loss of reduction

ORIF:

Open reduction and internal fixation

PMF:

Posterior malleolus fragment

ROC:

Receiver operating characteristic

SSI:

Surgical site infections

sSSI:

Superficial surgical site infections

References

  1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures - An increasing problem? Acta Orthop Scand. 1998;69:43–7.

    Article  CAS  Google Scholar 

  2. Daly PJ, Fitzgerald RH Jr, Melton LJ ID. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand. 1973;58(5):539–44 (Acta Orthop Scand. 1987; Bray).

    Article  Google Scholar 

  3. Jensen S, Andersen B, Mencke S, Nielsen P. Epidemiology of ankle fractures. Acta Orthop Scand. 1998;69:48–50.

    Article  CAS  Google Scholar 

  4. Juto H, Nilsson H, Morberg P. Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 2009–2013 and classified according to AO/OTA. BMC Musculoskelet Disord. 2018;19:1–9.

    Article  Google Scholar 

  5. Elsoe R, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg. 2018;24:34–9.

    Article  Google Scholar 

  6. Zaghloul A, Haddad B, Barksfield R, Davis B. Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases. Injury. 2014;45:780–3.

    Article  Google Scholar 

  7. Diveley RL. Fractures about the ankle. Mo Med. 1951;48:437–41.

    CAS  PubMed  Google Scholar 

  8. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37:691–7.

    Article  Google Scholar 

  9. Ovaska MT, Madanat R, Honkamaa M, Mäkinen TJ. Contemporary demographics and complications of patients treated for open ankle fractures. Injury. 2015;46:1650–5.

    Article  Google Scholar 

  10. Michelson JD. Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg. 2003;11:403–12.

    Article  Google Scholar 

  11. Schepers T, De Vries MR, Van Lieshout 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;37:489–94.

    Article  Google Scholar 

  12. Carragee J, Csongradi JBE. Early complications in the operative treatment of ankle fractures Influence of delay before operation. J Bone Jt Surg. 1991;73:79–82.

    Article  CAS  Google Scholar 

  13. Burwell NH, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Jt Surg. 1965;47:634–60.

    Article  CAS  Google Scholar 

  14. Pina G, Fonseca F, Vaz A, Carvalho A, Borralho N. Unstable malleolar ankle fractures: evaluation of prognostic factors and sports return. Arch Orthop Trauma Surg. 2021;141:99–104.

    Article  Google Scholar 

  15. Sculco PK, Lazaro LE, Little MM, Berkes MB, Warner SJ, Helfet DL, et al. Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures. Arch Orthop Trauma Surg. 2016;136:9–15.

    Article  Google Scholar 

  16. Breederveld RS, van Straaten J, Patka P, van Mourik JC. Immediate or delayed operative treatment of fractures of the ankle. Injury. 1988;19:436–8.

    Article  CAS  Google Scholar 

  17. Naumann MG, Sigurdsen U, Utvåg SE, Stavem K. Associations of timing of surgery with postoperative length of stay, complications, and functional outcomes 3–6 years after operative fixation of closed ankle fractures. Injury. 2017;48:1662–9.

    Article  CAS  Google Scholar 

  18. Höiness P, Engebretsen L, Strömsöe K. Soft tissue problems in ankle fractures treated surgically A prospective study of 154 consecutive closed ankle fractures. Injury. 2003;34:928–31.

    Article  Google Scholar 

  19. Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22:642–8.

    Article  Google Scholar 

  20. Fogel GR, Morrey BF. Delayed open reduction and fixation of ankle fractures. Clin Orthop Relat Res. 1987;215:187–95.

  21. James LA, Sookhan N, Subar D. Timing of operative intervention in the management of acutely fractured ankles and the cost implications. Injury. 2001;32:469–72.

    Article  CAS  Google Scholar 

  22. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Jt Surg - Ser A. 2009;91:1042–9.

    Article  Google Scholar 

  23. Hughes JL, Weber H, Willenegger HKEH. Evaluation of ankle fractures: non-operative and operative treatment. Clin Orthop Relat Res. 1979;138:111–9.

    Google Scholar 

  24. Carragee JCJ. Increased rates of complications in patients with severe ankle fractures following interinstitutional transfers. J Trauma. 1993;35:767–71.

    Article  CAS  Google Scholar 

  25. Wijendra A, Alwe R, Lamyman M, Grammatopoulos GA, Kambouroglou G. Low energy open ankle fractures in the elderly: Outcome and treatment algorithm. Injury. 2017;48:763–9.

    Article  Google Scholar 

  26. Bardenheuer M, Philipp T, Obertacke U. Treatment results after primary mangement of severely dislocated ankle fractures with. Unfallchirurg. 2005;108:728–36.

    Article  CAS  Google Scholar 

  27. Bartoníček J, Rammelt S, Kostlivý K. Bosworth fracture complicated by unrecognized compartment syndrome: a case report and review of the literature. Arch Orthop Trauma Surg. 2021. https://doi.org/10.1007/s00402-021-03815-1.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Haidukewych GJ. Temporary External Fixation for the Management of Complex Intra- and Periarticular Fractures of the Lower Extremity. J Orthop Trauma. 2002;16:678–85.

    Article  Google Scholar 

  29. Smeeing DPJ, Briet JP, van Kessel CS, Segers MM, Verleisdonk EJ, Leenen LPH, et al. Factors Associated With Wound- and Implant-Related Complications After Surgical Treatment of Ankle Fractures. J Foot Ankle Surg. 2018;57:942–7.

    Article  Google Scholar 

  30. Wawrose RA, Grossman LS, Tagliaferro M, Siska PA, Moloney GB, Tarkin IS. Temporizing External Fixation vs Splinting Following Ankle Fracture Dislocation. Foot Ankle Int. 2020;41:177–82.

    Article  Google Scholar 

  31. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1–S170.

  32. Yin M, Yuan X, Ma J, Xia Y, Wang T, Xu X, et al. Evaluating the Reliability and Reproducibility of the AO and Lauge-Hansen Classification Systems for Ankle Injuries. Orthopedics. 2015;38(7):e626-30.

    Article  Google Scholar 

  33. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27:97–132.

    Article  CAS  Google Scholar 

  34. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med. 2007;8:326–31.

    Article  Google Scholar 

  35. Müller ME, Allgöver M, Schneider R, Willenegger H. Manual of internal fixation. 3rd ed. Berlin: Springer; 1992.

    Book  Google Scholar 

  36. Baker JR, Patel SN, Teichman AJ, Bochat SES, Fleischer AE, Knight JM. Bivalved Fiberglass Cast Compared With Plaster Splint Immobilization for Initial Management of Ankle Fracture-Dislocations: A Treatment Algorithm. Foot Ankle Spec. 2012;5:160–7.

    Article  Google Scholar 

  37. Neumann AP, Rammelt S. Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases. Arch Orthop Trauma Surg. 2021. https://doi.org/10.1007/s00402-021-03875-3.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Mittlmeier T, Bartoníček J, Rammelt S. Das posteriore Tibiakantenfragment bei der Fraktur des oberen Sprunggelenks. Fuss und Sprunggelenk. 2016;14:79–93.

    Article  Google Scholar 

  39. Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg. 2015;41:587–600.

    Article  Google Scholar 

  40. Rammelt S, Zwipp H, Mittlmeier T. Therapie der Sprunggelenksluxationsfrakturen vom Pronationstyp. Oper Orthop Traumatol. 2013;25:273–93.

    Article  CAS  Google Scholar 

  41. Switaj PJ, Weatherford B, Fuchs D, Rosenthal B, Pang E, Kadakia AR. Evaluation of Posterior Malleolar Fractures and the Posterior Pilon Variant in Operatively Treated Ankle Fractures. Foot Ankle Int. 2014;35:886–95.

    Article  Google Scholar 

  42. Weber M, Ganz R. Malunion following trimalleolar fracture with posterolateral subluxation of the talus - Reconstruction including the posterior malleolus. Foot Ankle Int. 2003;24:338–44.

    Article  Google Scholar 

  43. Buyukkuscu MO, Basilgan S, Mollaomeroglu A, Misir A, Basar H. Splinting vs temporary external fixation in the initial treatment of ankle fracture-dislocations. Foot Ankle Surg. 2021; xxxx. https://doi.org/10.1016/j.fas.2021.03.018.

Download references

Acknowledgements

Not applicable.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

Authors

Contributions

RG was involved in the conception and design of the study. He collected, analysed and interpreted data. He classified x-ray and was writing the manuscript. AT was involved in the conception and design of the study. He substantively revised the manuscript. MJ analysed and interpreted data. He measured PMF on the x-ray and substantively revised the manuscript. VZ analysed and assisted the interpretation of data. PP was involved in the conception and design of the study. He classified x-ray and substantively revised the manuscript. All authors read and approved the final manuscript. They have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Corresponding author

Correspondence to Primoz Potocnik.

Ethics declarations

Ethics approval and consent to participate

The study was performed in accordance with the Declaration of Helsinki and the study, including its experimental protocols, was approved by the local Ethics Commission (Swiss ethics Project-ID: 2019–01494). All methods were carried out in accordance with relevant guidelines and regulations.

All patients gave informed consent for further use of individual person’s data on our institutional consent form.

Consent for publication

Patients gave informed consent for further use of individual person’s data on our institutional consent form.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Gerlach, R., Toepfer, A., Jacxsens, M. et al. Temporizing cast immobilization is a safe alternative to external fixation in ankle fracture-dislocation while posterior malleolar fragment size predicts loss of reduction: a case control study. BMC Musculoskelet Disord 23, 698 (2022). https://doi.org/10.1186/s12891-022-05646-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12891-022-05646-6

Keywords

  • Ankle fracture-dislocation
  • Malleolar fracture
  • Closed reduction
  • Cast immobilization
  • External fixator
  • Volkmann fragment