Immediate versus Delayed Surgical Intervention Following Ankle Fractures: A Retrospective ReviewAndrew Bernhard DPM PGY31, Jorge Matuk DPM2

1Chief Resident, Kingwood Medical Center, Kingwood, TX 2Residency Director, Kingwood Medical Center, Kingwood, TX

BACKGROUNDThe most common fractures affecting the foot and ankle are ankle fractures. A 2014

epidemiology article by Shibuya et. al. identified that 56% of fractures within the podiatric

scope of practice occur through the ankle. While many of these fractures will be referred to

orthopedic physicians, within our institution the podiatric residents are generally the first

line of treatment. Owing to a unique relationship with the emergency department, it has

become standard for the residents to be the paged first for attempts at closed reduction

and for surgical evaluation. Because of the nature of the timing, residents and attending

physicians are often able to schedule immediate open reduction and internal fixation of

these ankle fractures before significant edema presents.

While immediate ORIF is often contraindicated due to severe trauma, it has been our

experience that, due to the low energy involved in ankle fractures, there may anecdotally be

fewer wound complications than expected with immediate surgical intervention for these

fractures. Utilizing a modification of Sanders’ wrinkle test, post-traumatic edema is

identified by pinching the skin over the surgical site and noting skin wrinkles. Should

wrinkles be present, surgery would be performed prior to discharge from the hospital and

emergency department. Those patients with edema already present were thought to

benefit from traditional timing of surgery, due to increased risk of wound complications.

METHODS

A retrospective chart review was performed at our institution from July

2011 until July 2014 in order to identify all patients who were treated by

the senior author (JAM) for ankle fractures. All fractures managed with

definitive conservative treatment (n=4) were excluded from the study, as

were those with under one year of follow up. No exclusion criteria

regarding type of fracture, open or closed, number of malleoli involved, or

comorbidities were instituted. A total of 39 consecutive ankle fractures

were identified utilizing these search criteria. All ankle fractures were

closed reduced in the emergency department, with 28 of those reductions

being performed by the on-call podiatric resident emergently.

Appropriateness of operative timing was verified utilizing the skin wrinkle

test, adapted from Sanders description associated with calcaneal

fractures. If skin wrinkles were noted where the operative incisions would

be located, i.e. laterally for fibular fractures and medially if deltoid or

medial malleolar fixation was required, surgery was performed. The

patients were operated on immediately, defined as within the first 24

hours, delayed but before edema formation, from 24 to 48 hours, or

traditionally after resolution of edema.

All sutures were removed at two weeks post-operatively. The patients

were maintained in the splint, non-weightbearing, until clinical signs of

healing were noted, including absence of pain on palpation of the fracture

site and lack of motion at the fracture site. Patients began weightbearing

as tolerated in a CAM boot until radiographic union, where they could

transition to normal shoe gear as tolerated.

OBJECTIVES

• To identify any problems associated with immediate open reduction and internal

fixation of displaced ankle fractures

• To determine the efficacy of a modified Wrinkle Test in pre-operative planning and

timing of surgical intervention for these fractures

• To explore any benefit of podiatric involvement in the early management of ankle

fractures in the emergency department setting

RESULTS

Table 1: Breakdown of Surgical Techniques

Number PercentWound

Dehiscence

Immediate

ORIF25 64.1 1 (3%)

Delayed ORIF 4 10.3 0

Traditional

ORIF10 25.6 0

Total 39 100 1 (3%)

Figure 4 Figure 5 Figure 6 Figure 7

Preoperative and postoperative radiographs for patient in Figure 2 below

• Of 39 ankle fractures fixed operatively, 64% were treated within

one day of injury. An additional 10% were fixated prior to edema

formation.

• All patients who underwent open reduction and internal fixation

went onto radiographic union, with no delayed unions, mal-unions,

or non-unions noted, regardless of time to operative fixation.

• Only one patient in the immediate fixation group (3%) had wound

dehiscence, medially and laterally, with exposure of the lateral

hardware noted. The wounds never developed deep infection and

healed with local wound care only, requiring no further surgical

intervention. No patients in the intermediate or delayed internal

fixation groups developed wound healing problems. There was no

significant difference noted in wound complication or infection

rates between the immediate and the delayed or traditional groups

(P=1.00).

RADIOGRAPHS

CONCLUSIONS• Performing immediate open reduction and internal fixation of

rotational ankle fractures appears to be safe an effective without any

increased risk of complications.

• The wrinkle test, originally described by Sanders and modified here for

ankle fractures by Matuk, is a reliable indicator of the soft tissue

envelope in these common injuries.

• With early involvement of the podiatric residency with closed

reductions of ankle fractures, the majority of these injuries were able to

be treated prior to formation of edema and with no significant adverse

results.

Figure 8 Figure 9 Figure 10 Figure 11

Preoperative and postoperative mortise and lateral views of a typical trimalleolar fracture

Table 2: Patient Demographics

Number

Age

< 50 years old

50 – 75 years old

> 75 years old

Avg 49.3 yrs

20 (51%)

16 (41%)

3 (8%)

Sex

Male

Female

16 (41%)

23 (59%)

Comorbid Conditions 21 (54%)

Diabetes Mellitus

Tobacco Use

Obesity

Hypothyroidism

Worker’s Compensation

5 (13%)

8 (21%)

9 (23%)

2 (5%)

1 (3%)

Fracture Type

Lateral Malleolar

Medial Malleolar

Bimalleolar Equivalent

Trimalleolar Equivalent

8 (21%)

1 (3%)

17 (43%)

13 (33%)

DISCUSSION

Timing of surgical intervention for fractures has been researched in the past,

with the general consensus being to wait until after edema is managed,

approximately 7-14 days after the initial trauma. Schepers et. al. showed a

significant reduction of wound and infection complications when ORIF was

performed as early as reasonably possible. Our research supports early to

immediate surgical intervention as well. The current poster presents evidence

that the wrinkle test is useful in predicting a viable soft tissue envelope.

Saithna et. al. found report similar findings, going a step further to suggest

that generally “delaying surgery until swelling has subsided completely is

unnecessary.” Finally, Westacott et. al. showed a significant increase in

hospital stay when surgical intervention was delayed longer than 24 hours.

Early involvement with the podiatric residency, as demonstrated, generally

allows for immediate ORIF.

MODIFIED WRINKLE TEST

Figure 2

Acceptable Skin Wrinkles

Figure 1

Acceptable Skin Wrinkles

Figure 3

Negative Wrinkle Sign with

fracture blister formation

References:

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. International Orthopaedics. 2013;37(3):489-494.

Saithna A, Moody W, Jenkinson E, Almazedi B, Sargeant I. The influence of timing of surgery on soft tissue complications in closed ankle fractures. European Journal of Orthopaedic Surgery & Traumatology. 2009;19(7):481-484.

Westacott DJ, Abosala AA, Kurdy NM. The Factors Associated with Prolonged Inpatient Stay after Surgical Fixation of Acute Ankle Fractures. The Journal of Foot and Ankle Surgery. 2010;49(3):259-262.