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Ankle Fractures in Older Adults

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New Information on Ankle Fractures in Older Adults

Studies show that more and more older adults are being treated for ankle fractures. Not only are there more of these injuries, but they are more severe. What's behind this change?

In the past, osteoporosis (decreased bone density or "brittle bones") was blamed for most ankle fractures in adults 65 years old and older. Osteoporosis is linked with hip, wrist, and shoulder fractures. But new data suggests there are other possible more important risk factors. One of those risks is taking multiple medications called polypharmacy.

Being overweight appears to be the most common risk factor. The heavier body mass increases the force on the soft tissue and bony structures when a fall happens. But diabetes, cigarette smoking, and inactivity may be the real underlying culprits.

A sedentary lifestyle leads to weakness and deconditioning resulting in decreased balance and increased risk of falls. People who have to push up with their arms to get out of a chair are more likely to suffer a fall and broken ankle.

Many older adults with ankle fractures aren't doing dramatic things when the injury occurs. They aren't sliding into home plate or skydiving. More often, these are low-energy injuries involving pressure, load, and a twisting motion of the ankle.

Even in active seniors who are physically fit, stopping a bike on an uneven surface, stepping down from a curb, or walking along a patch of grass with dips and bumps can do it. The twisting motion is enough to tear one or more of the many supportive ankle ligaments (e.g., anterior and posterior talofibular ligaments, calcaneofibular ligament, deltoid ligament, tibiocalcaneal ligament, tibiotalar ligament).

Without this important soft tissue structure, the force continues through the bone causing a spiral or oblique (at an angle) break in one or both of the bones along side the ankle.

The areas affected are the distal (bottom end) of the tibia (large bone in the lower leg) and the fibula (smaller bone in the lower leg). The fractures occur right where the "bumps" are located on either side of the ankle -- what most people call their "ankle bones." The anatomical term for this area is malleolus (malleoli, plural).

Once the deed is done, how should the fracture be treated? The first step is to determine if the fracture is stable (nondisplaced) or unstable (displaced or separated, bones shifted apart).

The primary care physician or orthopedic surgeon visually inspects the injury, palpates (feels) for broken bones, and (if possible) tests ankle motion. X-rays and other imaging studies (e.g., CT scans, MRIs) are used to confirm the diagnosis.

A broken but stable ankle can be put in a cast brace or walking cast. The patient is allowed to put full weight on the bones. An unstable fracture must be reduced -- meaning the two ends of the bones are separated apart if they are jammed together and overlapping.

If the bones are separated apart, the ends are realigned and matched back up as closely as possible. Sometimes a closed reduction is possible (without surgery using traction). Most of the time, surgery is required. That all sounds like it's very simple -- a cut and dried decision. But it's not.

There are many factors that impact the treatment decisions whether or not to have surgery. And if surgery is done, what's the best way to approach the problem? Should the bones be wired back together? Should screws be used instead? When should the surgeon reinforce the screws with glue to hold them in place?

What if the patient does have osteoporosis? Does that affect the way treatment is carried out? Some surgeons are trying the new locked plating system to hold bones together that are weakened by osteoporosis and may not otherwise be able to handle screws placed through the bone.

The locked plating system is a new technology still being investigated. But the fact that it doesn't have to be compressed onto the bone yet can withstand torsional and bending forces are major advantages of this system.

All risk factors for poor recovery should be identified. Physicians and patients should be prepared for possible complications. The most likely problems include delayed wound healing, infection, pain from the hardware (which is often sticking out), and malunion (bones don't heal properly lined up).

Management of the condition may include reducing risk factors for future ankle fracture injuries. Consideration is given to the fact that any hardware put in to stabilize the joint must be taken out later. That requires another operation, which costs more money and puts the older at-risk patient at greater risk for additional complications and problems.

In summary, there are many questions being studied right now about the optimal treatment of ankle fractures in older patients. No definitive ("for sure") answers are ready. Physicians are advised to review each case individually and carefully.

Reference: Eric J. Strauss, MD, and Kenneth A. Egol, MD. Identifying and Managing Ankle Fractures in Older Patients. In The Journal of Musculoskeletal Medicine. April 2011. Vol. 28. No. 4. Pp. 137-147.

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