Timely recognition and reduction of ankle fracture-dislocation may have an impact on mid-term patient reported outcomes

L. Wicks, D. Richler-Potts, A. Bowden, D. Clarke, J. Mangwani

Introduction: Significantly displaced ankle fractures frequently suffer a delay to manipulation whilst waiting for x-rays, with the potential for worsening soft tissue trauma. The purpose of this study was to establish how often ankle fracture-dislocations presenting to the emergency department (ED) are identified and reduced on clinical assessment alone; and does performing an x-ray before reduction lead to a less favourable patient reported outcome.

Method: Radiographs were assessed for all patients who had an ankle fracture fixation at the Leicester Royal Infirmary between March 2012 and February 2013. Ankle fractures with significant displacement or those already in a cast (after manipulation) on the initial radiographs were selected for further analysis. In addition the patient reported outcomes measured were Lower Extremity Functional Scale (LEFS) and Olerud-Molander Ankle Scores (OMAS).

Results: One hundred and nineteen patients were identified for analysis. 62 patients had significantly displaced ankle fractures not in a cast on initial radiographs, whilst 57 were. There was no difference in the likelihood of the initial fracture manipulation being successful between these two groups. (P=0.8507). On average, from the time of arrival to hospital, it took over an hour longer for a patient, who was initially sent to x-ray, to have a radiograph confirming an adequately reduced ankle mortice post manipulation (p=0.0024). 67 of 119 patients responded to the postal questionnaires. LEFS and OMAS scores at 2 years were better in patients who underwent early reduction that was successful on the first attempt, without pre-manipulation radiographs.

Conclusion: Pre-manipulation x-rays did not improve the chance of a successful initial attempt at fracture reduction. However, the time to achieve a reduced ankle mortice was significantly longer when x-rays were first performed. The delay appears to have an impact on mid-term patient reported outcomes.