Rockwood Adults CH64

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SECTION FOUR • Lower Extremity

A

C

B

Figure 64-26.  A: The appearance of the soft tissues after an ankle fracture in an 84-year-old woman with dementia and very low functional demands. B: A retrograde calcaneotalotibial nail has been used to stabi- lize the fracture. C: Stab incisions were used to insert the nail and locking screws.

Following operative fixation of ankle fractures, rates of symptomatic DVT of between 0.05% 351 and 0.12% 166 have been reported, with an associated risk of PE of between 0.17% 166 and 0.34%. 351 While a recent Cochrane meta-analysis 430 indicated a role for LMWH after lower limb injury, the analysis was based on papers with heterogenous injury groups using venographically- identified, rather than clinically relevant, thrombi. In contrast, two recent large RCTs and a meta-analysis have confirmed the very low rate of clinically relevant venous thromboembolic events after ankle fracture and below-knee immobilization and have shown that there is no role for routine DVT prophylaxis in these patients. 299,339,394 Future research may be able to iden- tify high-risk groups who might benefit from such prophylaxis, such as those with multiple comorbidities, 166,351 obesity, 343 open fractures, 351 associated injuries (higher ISS), 343 and age over 50 166,343,351 who have all been reported to be associated with increased incidence of VTE.

movements has also been debated. Conclusive evidence of the benefits of one form of immobilization over any other is lacking. While some comparisons of functional bracing and cast immobilization favor functional bracing, 101 others have reported marginally better results with cast immobilization, cit- ing concerns regarding wound problems with functional brac- ing. 213 Other authors have simply found no major differences. 62 Critics of cast immobilization have reported a significant loss of bone mineral mass following lower limb cast immobilization in previously fit adolescents 57 and significant muscle atrophy on MRI. 310 Comparisons of soft bandaging with casting have been similarly equivocal. Søndenaa et al. 350 found a better range of movement in patients managed without immobilization at 6 weeks but no significant differences thereafter, a finding echoed by Finsen et al. 111 and Tropp and Norlin. 392 Weightbearing in plaster following ankle fracture fixation for most patients has long been shown to be safe with no increase in major complications, 2,3,111,136,396 indeed the Cochrane database identifies this fact as one of the few areas of surgi- cal treatment that has been well investigated. Weightbearing in an orthosis (thus allowing for early active movement) also appears safe. 4,62,147,346,392 Despite this overwhelming evidence, orthopedic surgeons have been shown to be somewhat con- servative, with high rates of restricted weightbearing. 368 There

Postoperative Care Immobilization

A number of different methods of immobilization have been investigated including soft bandaging, functional bracing and casting, while the time to initiation of weightbearing and active