Management of 'low-risk' ankle fractures in children: a systematic review

Abstract

Introduction: This study aimed to review the literature to establish whether there is a best treatment for low-risk ankle fractures in children.

Materials and methods: A systematic review and meta-analysis of trials was undertaken, which compared interventions for 'low-risk' ankle fractures in children. A meta-analysis was performed using a random effects model.

Results: Four trials were identified reporting outcomes from 256 patients. All trials reported results using a device that permitted ankle motion compared with more rigid immobilisation. Overall risk of bias was low for three trials and high for one trial. Two trials assessed time to return to normal function. Patients treated in a splint or with a bandage recovering 6-7.5 days sooner than those treated with rigid immobilisation. One trial demonstrated that children returned to school sooner if treated in a bandage rather than in a cast. Two trials found a higher Activity Scale for Kids performance score at four weeks for children treated with splint compared with rigid immobilisation. There was no clear advantage to any device in patient satisfaction, quality of life or total costs.

Discussion: There is no clear best treatment for these injuries. Studies had significant limitations and outcomes were heterogeneous, limiting meta-analysis.

Conclusion: There is a need for a definitive trial to establish the best treatment for ankle fractures and a core outcome set to ensure study findings are consistent and can be analysed in future meta-analyses.

Keywords: Ankle; Ankle injuries; Children; Fractures; Pediatrics; Systematic review.

Figure 1

PRISMA flow diagram.

Figure 2

Forest plot for three trials^,, of return to function defined as return to school or all normal activities. Summary diamond for return to normal activities using random effect model. Positive values favour the use of a mobile brace (I = 0%).

Figure 3

Forest plot of mean difference in function for two trials^, at four weeks. Scores are the Activity Scale for kids given in %. Summary diamond constructed with random effects model. Positive values favour the use of a mobile brace (I = 0%).

Figure 4

Forest plot for pain reported in three studies.^,, Barnett et al reported the number of days for which simple analgesia was required. Boutis et al reported pain at 4 weeks using the faces pain scale, this has been converted into 10-point scale for comparison. Launay et al reported pain on a 10-point score at 1 week post injury. Summary result is for pain scores. Positive values favour the use of a mobile brace (I = 0%).