Special Considerations in the Management of Diabetic Ankle Fractures

Abstract

Purpose of review: Ankle fractures and diabetes mellitus are both increasing in prevalence. Patients with both diabetes and an ankle fracture have been shown to have an increased rate of complications which can be catastrophic. The purposes of this review are to identify factors placing patients at an increased risk and offer guidance on the management of these injuries, in order to reduce potential complications.

Recent findings: Non-operative management of unstable ankle fractures in patients with diabetes results in an unacceptably high rate of complications. Operatively managed patients with uncomplicated diabetes seem to fair as well as patients without diabetes. Thus, it is important to recognize patients as either complicated or uncomplicated at the onset of their treatment based on comorbidities. There is limited evidence to guide the management of ankle fractures in patients with diabetes, in particular those deemed complicated. Non-operative management of unstable fractures in diabetic patients should be avoided.

Keywords: Ankle fracture complications; Ankle fracture fixation; Charcot neuroarthropathy; Diabetic ankle fracture.

Fig. 1

A 54-year-old insulin-dependent female treated non-surgically at an outside facility for a ground level fall, presenting for ankle pain and deformity 8 months after injury. Patients with diabetes, peripheral neuropathy, and ankle fractures should be monitored closely with serial imaging for the development of Charcot neuroarthropathy so as to facilitate timely intervention as needed before deformity progresses

Fig. 2

A seemingly innocuous non-displaced Weber B distal fibula fracture in a 72-year-old female with insulin-dependent diabetes, COPD, and peripheral arterial disease. This patient was a minimal home ambulator. She did have peripheral neuropathy and was immobilized and recommended to be discharged to a skilled facility due to fall risk

Fig. 3

This same patient presenting 10 days later. X-rays now reveal displacement at the medial malleolus and a trimalleolar ankle fracture

Fig. 4

The same patient 4 months post-operatively after undergoing closed application of an intramedullary nail. The patient was permitted to weight-bear 3 weeks post-operatively for pivot and transfers and then permitted full weightbearing in a walking boot 6 weeks after surgery

Fig. 5

A 57-year-old male with type 2 diabetes, obesity and peripheral neuropathy treated with ORIF with use of locked plating, multiple syndesmotic screws, and a supplementary medial anti-glide plate

Fig. 6

An 82-year-old non-insulin-dependent female treated for a trimalleolar ankle fracture with open reduction and internal fixation. Direct lateral plating was utilized and she subsequently developed a non-infected surgical wound with exposed hardware. She was monitored closely off of antibiotics with serial laboratories and imaging. Fourteen weeks after initial ORIF, with her fracture radiographically healed, she underwent removal of hardware and healed uneventfully by means of secondary intention within 4 weeks. The authors find that this direct lateral approach with direct lateral plating has a particularly high risk of wound development in elderly diabetic patients

Fig. 7

A 56-year-old insulin-dependent male with a history of end-stage renal disease on hemodialysis, peripheral neuropathy, retinopathy, and trans-metatarsal amputation for osteomyelitis. The patient underwent initial ORIF with locked plating and subsequently developed a severe deep infection which was treated with explant of hardware and transition to definitive ring external fixation

Fig. 8

A 72-year-old insulin-dependent female with renal insufficiency, peripheral neuropathy, and a history of first ray amputation for osteomyelitis. She presented with a 1-week-old ankle injury and pain with swelling. She was prompted to come to the emergency department when she had spontaneous bleeding from her ankle

Fig. 9

Employing a staged protocol, the patient was treated with a pin and bar external fixator and multiple washouts with closure of her medial wound and delayed primary ankle arthrodesis with intramedullary nail