Reduction of Ankle Fractures

[ldsrmdude]

Building off of a few posts in the True Stories from Podiatric Residency thread, I thought a discussion about the reduction of ankle fractures would be interesting. I'd be curious to know your technique, whether you do it under conscious sedation or with a hematoma block (or both), whether you get pre- and post-reduction x-rays, what sort of a splint do you use post-reduction, etc.

Anyone care to chime in? Students, residents, attendings, etc...

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[josebiwasabi]

I helped reduce a tri-malleolar fracture when I was visiting a program as a 2nd year. It was an elderly man who had slipped on ice as he was walking around his block. The resident on-call got paged by the ED to take a look at this guy to reduce his ankle. On x-ray you could see that his talus was severely anteriorly displaced and we were very concerned about the integrity of the DP.

The patient was given a lot of morphine for pain management during our closed reduction... but I don't really think it helped him much.

Pt was supine with hip and knee flexed at 90 degrees. We had 3 people involved in the reduction. One of the techs helped stabilize the knee at 90 degrees. My job was to stabilize the distal tibia. The resident was distracting the ankle and then trying to reduce it. At that point in time I didn't really know much about ankle fractures or closed reduction so a lot of the subtleties of what was happening probably went unnoticed. We took post-reduction films and the talus was in good alignment but the both malleoli were displaced. I don't remember whether or not he had a splint placed on him. I believe he went to the OR the following day for ORIF.

 

[janV88]

For splint I would always use a 3 sided splint (posterior splint with "sugar tongs"). A posterior splint stabilizes the ankle in the sagital plane while the "sugar tongs" stabilize in the transverse and frontal plane. Stabilization in the transverse and frontal plane is very important in ankle fractures. Think of the mechanism of most ankle fractures. 75% or so SER and PER. So that's supination/pronation (frontal plane) and external rotation (transverse plane).

For anesthesia. Anyone that has ever seen an ankle fracture reduction will tell you that versed and morphine or fentanyl is inadequate. It's like torture for the patient and they require high doses. Plus high doses of opiates will cause respiratory depression. Meaning you are putting the ER doc on the hook for sometime after you perform your reduction. IMO conscious sedation per ER doc with a little morphine is most ideal and from my experience, this is what ER docs prefer. I do not have any experience with hematoma blocks.

 

[ldsrmdude]

It's imperative to reduce stress on the soft tissues in an expedited manner.

Do you wait to get pre-reduction X-rays? Why or why not?

 

[janV88]

Do you wait to get pre-reduction X-rays? Why or why not?

I would definitely get X-rays prior to know exactly what you're dealing with. The ER docs should already have X-rays if they are calling you.

 

[msuDPM]

Not a bad conversation regarding reductions. Agree with most everything that has been said regarding technique/splinting. Thought I would add that I have never used conscious sedation on an ankle reduction. I give the same block every time: common peroneal, hematoma, intraarticular ankle, and PT just proximal to deformity. Generally use 20-30cc of local, has always worked well for me. Admittedly I have not had to reduce a peds ankle fx as we don't see much peds trauma in our ED. Don't mean to discount conscious sedation at all, it is a great tool. We have used it for a couple STJ/TN dislocations as they can be fairly graphic when REALLY pulling on a pts forefoot.

 

[ldsrmdude]

I would definitely get X-rays prior to know exactly what you're dealing with. The ER docs should already have X-rays if they are calling you.

I'm just curious (and trying to keep a good discussion going), but let me just present a hypothetical scenario. You're in the ED when a patient comes in with a closed ankle fracture. Obvious deformity. Tenting of the skin from the deformity. Patient complaining of some tingling. Reduce the fracture or get x-rays?

 

[dtrack22]

I'm just curious (and trying to keep a good discussion going), but let me just present a hypothetical scenario. You're in the ED when a patient comes in with a closed ankle fracture. Obvious deformity. Tenting of the skin from the deformity. Patient complaining of some tingling. Reduce the fracture or get x-rays?

What happens when you didn't get X-rays and that closed fx was a pilon that you didn't put a frame on and keep out to length?

 

[Pronation]

I'm just curious (and trying to keep a good discussion going), but let me just present a hypothetical scenario. You're in the ED when a patient comes in with a closed ankle fracture. Obvious deformity. Tenting of the skin from the deformity. Patient complaining of some tingling. Reduce the fracture or get x-rays?

Wouldn't you want to get x-rays, reduce, then take another x-ray just to CYA?

 

[PMSIII]

Great discussion. I agree with the aforementioned regarding reduction techniques and respecting the soft-tissues. Pre-reduction radiographs should be a given. If I am involved in the reduction, then I like to give a common peroneal nerve block at the fibular head to help reduce the peroneal muscle involvement - I can't say if this works for everyone, but I've been doing this since residency without issues. I, then take films post-reduction and if the reduction is poor, they are going to the OR for either Ex-fix, or ORIF.

 

[dtrack22]

pre-reduction films at our hospital take minutes to obtain. Plus, the ED docs will have it ordered before we are even called so that's never been an issue in my limited experience.

My decision making process for hematoma block v conscious sedation is based on the severity of the dislocation. However, I will lean heavily towards conscious sedation for awhile (I've been a resident for a whole month), until I get better at reducing ankles first shot. Part of my reasoning is based on a failed reduction with just a hematoma block in the urgent care. Patient was NOT happy, which though it sounds mean isn't really my main concern, but more importantly I didn't get it reduced until she was transferred to the ED, sedated, and stopped fighting the distraction and reduction.

For conscious sedation we use a combo of ketamine and propofol. ED docs take care of the order and dosing if we give them a heads up on our way in.

 

[janV88]

My concern with common peroneal and tibial nerve blocks is, how do you assess neuro status post reduction?

 

[PMSIII]

My concern with common peroneal and tibial nerve blocks is, how do you assess neuro status post reduction?

I don't think you really can post-reduction - they'll be in a splint most likely and swollen from the trauma, so I don't expect much past checking their epicritic sensation at the toes or at the ankle pre-reduction.

 

[janV88]

I don't think you really can post-reduction - they'll be in a splint most likely and swollen from the trauma, so I don't expect much past checking their epicritic sensation at the toes or at the ankle pre-reduction.

For neuro status I ask if they have any numbness, tingling, burning. Then I check if sensations equal bilaterally to toes. Then have them wiggle their toes.

All of which are diminished with a block. So how do you know if they don't have any neuro insult if you can't test it? What about compartment syndrome symptoms?

 

[ldsrmdude]

What happens when you didn't get X-rays and that closed fx was a pilon that you didn't put a frame on and keep out to length?

Post-reduction x-rays will show you if do have that pilon fracture. At that point, taking it to the OR and bringing it out to length is what I would do. Mind you, I'm just talking in hypotheticals here. I don't think I've ever reduced an ankle fx without pre-reduction films. It wouldn't stop me from doing it depending on the situation, however.

For neuro status I ask if they have any numbness, tingling, burning. Then I check if sensations equal bilaterally to toes. Then have them wiggle their toes.

All of which are diminished with a block. So how do you know if they don't have any neuro insult if you can't test it? What about compartment syndrome symptoms?

I personally haven't found that asking patients about about numbness and tingling post-reduction really provides me much information. A lot of them have numbness and tingling from the injury, and just reducing the ankle doesn't always make that stop. Like PMSIII said, they're going to be in a splint anyways, so it's tough to check for much in terms of neurologic trauma. You're checking for all of these things pre-reduction, as much as possible anyways.

 

[dtrack22]

Post-reduction x-rays will show you if do have that pilon fracture. At that point, taking it to the OR and bringing it out to length is what I would do. Mind you, I'm just talking in hypotheticals here. I don't think I've ever reduced an ankle fx without pre-reduction films. It wouldn't stop me from doing it depending on the situation, however.

Sure, but now you wasted how much time reducing and splinting something that needed to roll back to the OR anyways? I get that you haven't blown the opportunity to fix the pilon, for example, I just don't see the point in forgoing a test that could be done in the time it took you to grab your webril, plaster and ace.

What about compartment syndrome symptoms?

Good point. I don't see the need for a block, regardless of how I feel about potential post-block ramifications. If you're really worried about reducing the fx, conscious sedation, otherwise a hematoma block will work fine. To add, people who aren't concerned about compartment syndrome or aren't worried about masking the signs/symptoms probably don't see enough trauma.

 

[PMSIII]

For neuro status I ask if they have any numbness, tingling, burning. Then I check if sensations equal bilaterally to toes. Then have them wiggle their toes.

All of which are diminished with a block. So how do you know if they don't have any neuro insult if you can't test it? What about compartment syndrome symptoms?

A common peroneal block won't diminish your ability to diagnose a compartment syndrome in the acute setting. You can do all of the aforementioned checks pre-block then give the block. I didn't say ignore the physical examination component. History and Physical are crucial. The purpose of the block is to help your reduction and treatment after you made your proper assessment

 

[PMSIII]

Sure, but now you wasted how much time reducing and splinting something that needed to roll back to the OR anyways? I get that you haven't blown the opportunity to fix the pilon, for example, I just don't see the point in forgoing a test that could be done in the time it took you to grab your webril, plaster and ace.



Good point. I don't see the need for a block, regardless of how I feel about potential post-block ramifications. If you're really worried about reducing the fx, conscious sedation, otherwise a hematoma block will work fine. To add, people who aren't concerned about compartment syndrome or aren't worried about masking the signs/symptoms probably don't see enough trauma.

Compartment syndrome is absolutely crucial especially with the right history - high energy/pilon/etc. Although, not very common in the setting of isolated bi-trimalleolar trauma - one should always keep in mind. In a situation like that, the right course would be a trip to the OR and external fixation right away.

 

[ldsrmdude]

Sure, but now you wasted how much time reducing and splinting something that needed to roll back to the OR anyways? I get that you haven't blown the opportunity to fix the pilon, for example, I just don't see the point in forgoing a test that could be done in the time it took you to grab your webril, plaster and ace.

You're ER must be more efficient at taking x-rays than mine 🙂
Actually, your post makes me curious. Do you typically use plaster for your splints? We almost always do fiberglass.

 

[dtrack22]

You're ER must be more efficient at taking x-rays than mine 🙂
Actually, your post makes me curious. Do you typically use plaster for your splints? We almost always do fiberglass.

Depends. All OR/post-op and most ED posterior splints, we use the pre-packaged fiberglass. Plaster for all sugar tongs. A really unstable fx or one that you are reducing by yourself, plaster for both. The other residents may have different thresholds as to when they will use plaster for the posterior splint but that's pretty standard at our program

 

[janV88]

A common peroneal block won't diminish your ability to diagnose a compartment syndrome in the acute setting. You can do all of the aforementioned checks pre-block then give the block. I didn't say ignore the physical examination component. History and Physical are crucial. The purpose of the block is to help your reduction and treatment after you made your proper assessment

I re-read your previous post and I think I may have misunderstood you. Do you only do a common peroneal block or is this in addition to a hematoma block?

 

[Pronation]

Here's a video I found where the ED reduced the ankle and applied a posterior splint with sugar tong.