Ankle fractures are the third most common fracture in older adults, after hip and radius fractures.
Ankle fractures themselves are not classic osteoporotic injuries. However, bimalleolar and trimalleolar fractures in older patients meet criteria for osteoporotic fractures. Managing ankle fractures in older adults requires special treatment.
1.Age-related changes have a decisive influence on the outcome after ankle injury
In addition to bone aging and osteoporosis in older patients compared with younger patients, age-related changes in peripheral nerves, blood vessels, and soft tissues have a decisive impact on the treatment and outcome of ankle injuries. This can lead to frequent complications such as impaired wound healing, necrosis, and implant failure.
In addition, nutritional and vascular disease and thin skin texture present in older adults can promote soft tissue complications.
2.What are the different injury mechanisms of ankle fractures in the elderly?
Compared with younger patients, elderly patients typically suffer from low-energy trauma, primarily from falls at home. Elderly patients often have more complex fracture patterns, multi-segment fractures.
In patients older than 60 years, there is a high proportion of Lauge-Hansen type III pronation-abduction fractures, and these fractures are considered highly unstable (below).
3. What are the differences in the diagnosis of ankle fractures in the elderly?
Preliminary diagnosis requires more than just skeletal examination results. Attention must be paid to the presence of coexisting medical conditions such as diabetes mellitus, peripheral vascular disease, osteoporosis, neurologic deficits, long-term medication (anticoagulation, corticosteroids) and the level of activity before the trauma, as these parameters have a decisive influence on the patient’s recovery. Imaging Studies Because complex fracture patterns are often found in elderly patients, additional CT studies are recommended. In older patients, complex ankle fractures such as this (picture below) occur in one in four cases. Peripheral arterial occlusive disease usually presents in older age, and adequate perfusion of the lower extremities is a prerequisite for wound and bone healing.
4. What are the different indications for the treatment of ankle fractures in the elderly?
As in younger patients, if subluxation or dislocation occurs, immediate reduction is required, especially given the fragility of the soft tissues of the distal calf and the possible cutaneous dystrophic disorders that may occur in older age. Subsequent retention uses a splint with good padding and stabilizing conditions.
The definitive treatment of ankle fractures in the elderly remains controversial. The most common complications of surgical treatment are impaired wound healing (7-13%), poor healing, and deep infection (1%). Risk factors for postoperative complications include advanced age, smoking, diabetes, osteoporosis and other local factors.
5. What are the different indications for surgical treatment?
Indications for surgical treatment depend largely on soft tissue status. The principles regarding fracture management are no different than in younger patients, i.e. precise anatomical reduction and articular surface, length and rotational stabilization of the fibula, etc. Elderly patients should pay attention to the use of non-invasive surgical techniques and choose a suitable incision approach. For unstable fractures, it is recommended to use an external fixator for fixation until the soft tissue is stable and perform a two-stage reconstruction and retention.
6. Precautions and techniques for surgical treatment
1). From a biomechanical perspective, implanting the posterolateral fibular plate and the posterolateral malleolus plate through the posterolateral approach can achieve more stable fixation in trimalleolar fractures.
2). The advantage of the posterolateral approach is good soft tissue coverage of the implant. (The following figure).
3). The posterolateral fibula plate can fix longer screws to the distal bicortex without penetrating the joint, thereby obtaining greater stability. Lag screws may also be implanted transverse to the fracture line to increase stability.
Techniques for plate fixation. The plate is first fixed to the proximal fibula segment (a) and then the lag screw is screwed in as a distal reduction tool (b). NOTE: Make sure the plate does not reach the top of the fibula to avoid irritating the peroneal tendon.
Use screws and washers to fix the bone fragments according to their size range.
4). To improve stability, excellent results can be achieved by using hook plates in combination with tibial-fibular screws. Some practitioners recommend a combination of 2 plates: one dorsally and one laterally to increase stability in multi-fragment fractures.
5). Peroneal intramedullary nailing provides a minimally invasive and soft-tissue-preserving option for stable fixation. It has a low incidence of complications, such as wound healing impairment or infection, good function and good patient satisfaction. The disadvantage is that anatomical reduction cannot always be achieved and partial damage to the calcaneal ligament at the tip of the fibula may occur due to nail entry.
6). Stabilization of the medial malleolus is particularly challenging in osteoporotic bones. Elderly patients are more likely to suffer medial malleolus fractures than younger patients. Tension bands have achieved better results in osteoporotic bone, small fragments, or avulsion fractures; tibial bicortical lag screws have also resulted in greater stability and better radiographic and clinical outcomes; also A hook plate is available, which may provide better results and stability, especially in older patients (image below).
7. Precautions for postoperative care
The main goal of treating ankle fractures in elderly patients is to restore previous mobility and activity levels and maintain good ankle function. Passive-active mobilization of the ankle joint should be performed as early as possible. Subsequent treatment depends on the soft tissue and depends on the quality of the bone. In general, close clinical and radiological follow-up is recommended to allow early detection of complications and enable timely intervention. Radiographic and soft tissue examinations are recommended every 14 days, especially during conservative management and in patients with diabetes.
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Post time: Nov-07-2023