NonOperative Treatment of Ankle Fractures

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- Avulsion frx of lateral malleolus (Weber A)
    - frequently does well w/ closed reduction;
    - w/ lateral and oblique medial malleolus injuries;
    - pronation of foot & abduction will reduce frx;
    - however, is an unstable pattern which requires operative Rx;

- SER/Weber B:
      - reduced by gentle distraction, internal rotation, and varus stress;
      - try placing limb in stockinette, injured side down, & then suspending
              free end of the stockinette, then apply cast;
              - be concerned w/ shortening and external rotation of fibula;
              - w/ an associated medial injury - may require surgery;

- Syndesmotic disruption (pronation-abduction/ext.rot or Weber C)
    - usually unstable and require operative stabilization;
    - w/ closed reduction try: distraction, inversion, & adduction;
    - lateral collateral ligaments are usually the only intact ligaments on
              distal fibula, and do not provide enough control of this fragment
              to correct and maintain fibular length and rotation;

- Indications for Treatment:
    - if in presence of medial tenderness, > 5 mm of space is seen either
              initially or on a stress radiograph, presumptive dx of substantial
              injury of the Deltoid Ligament can be made;
              - treat as bimalleolar frxs, w/ ORIF of lateral malleolus;
    - exploration of medial side of ankle is not necessary unless there is evidence
              of Deltoid Ligament disruption w/ ligament interposed in the joint, blocking
              reduction of the talus;

- Note: Isolated injuries of medial malleolus are uncommon and the
        possibility of an undisplaced lateral injury should be considered;
        - isolated fractures are treated closed if:
                - they are undisplaced
                - involve the distal portion of the malleolus
                - and can be anatomically reduced by manipulation;

- Maintenance of Reduction:
    - w/ swelling use a bulky Jones type dressing w/ plaster splints
    - stable/non-displaced ankle injuries:
    - after spinting for 3-5 days, try short leg cast: 4-6 wks;
    - wt bearing after symptoms subside;
    - w/ rotational instability: use long leg cast: 4-6 weeks, then short;
    - delay wt bearing until evidence of healing;
    - always avoid immbolization of the ankle in Equinus;