Management of ankle fractures in the elderly

Abstract

The incidence and severity of ankle fractures in elderly patients is increasing steadily. These injuries are challenging to treat and prone to complications.Individual fracture treatment is tailored depending on bone quality, skin conditions, comorbidities, and functional demand of the patient. This article provides a review of current techniques to obtain stable fixation despite poor bone quality. To avoid complications, it is imperative to consider and treat comorbidities such as diabetes and osteoporosis.In the absence of severe systemic comorbidities, the results after open reduction and internal fixation of malleolar fractures in patients above and below 60 years of age are nearly identical, while nonoperative treatment of unstable fractures leads to significantly inferior outcomes. Therefore, the general indications for surgery in elderly patients should not differ from those in younger patients.However, it is essential to detect severe conditions such as Charcot neuro-osteoarthropathy because these require a completely different treatment regime, and standard internal fixation will invariably fail in these patients. Cite this article: Rammelt S. Management of ankle fractures in the elderly. EFORT Open Rev 2016;1:239-246. DOI: 10.1302/2058-5241.1.000023.

Keywords: Charcot neuroarthropathy; complications; diabetes; dislocation; osteoporosis; posterior tibia; syndesmosis.

Fig. 1

Fracture-dislocation with impeding skin necrosis produced by a prominent medial fragment of the distal tibia. Immediate reduction is warranted.

Fig. 2 a, b

Trimalleolar fracture (pronation abduction stage 3) in a 79-year-old woman with severe osteoporosis.

Fig. 3

Tibiometatarsal transfixation is employed in cases of unstable fractures and fracture-dislocations, if a primary internal fixation is not feasible for various reasons (same patient as Fig. 2).

Fig. 4 (a, b)

CT scanning reveals a large posterior fragment with marginal impaction of the tibial plafond (same patient as Figs 2 and 3). Note the displacement of the posterior fragment that follows the distal fibular fragment held by the posteior syndesmosis.

Fig. 5 a, b

Internal fixation is achieved with a posterior and lateral interlocking plate, and screw fixation of the medial malleolus. c) Fixation of the posterior fragment stabilises the tibiofibular syndesmosis as demonstrated with the intra-operative hook test (same patient as Figs 2-4).

Fig. 6

a) Bimalleolar fracture (pronation abduction stage 3) in a 57-year-old woman with osteoporosis. b) Interlocking, contoured fibular plating is supplemented by two intramedullary K-wires that engage the medial cortex.

Fig. 7

a, b Failure of standard internal fixation in a 77-year-old diabetic patient with poor bone quality but without neuropathy. c) The lateral plate had to be removed because of wound dehiscence and wound edge necrosis to avoid deep infection. d, e) The ankle mortise was restored using three syndesmotic screws (tibia pro fibula) and intramedullary pinning of the lateral and medial malleolus because of the poor soft tissue conditions. f, g) At one year after revision surgery the fractures have healed with a stable and congruent mortise. h, i) The wounds have healed uneventfully with a broad lateral scar and ankle range of motion is almost completely restored. Note the missing fifth toe after a diabetic gangrene four years earlier.