How To Treat Ankle Fractures In Patients With Diabetes

By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Travis L. Sautter, DPM
Unfortunately, these patients have abnormal bone metabolism, which results in significant bone resorption and often rapid disintegration. Following an ankle fracture, this can result in progressive destruction over a relatively short period of time. The literature on the management of ankle fractures in patients with diabetes has shown outcomes to be generally poor. McCormick and Leith evaluated ankle fractures in 26 patients with diabetes mellitus and compared them to a group of non-diabetic patients. They found a 42.3 percent incidence of complications in patients with diabetes mellitus as opposed to no complications in the non-diabetic group. They concluded that conservative management may be preferable to surgical treatment in view of the high risks associated with management of ankle fractures with diabetes mellitus.6 However, Flynn, et. al., evaluated 98 patients with ankle fractures, 25 of whom had diabetes mellitus. The infection rate was 32 percent in the diabetes mellitus group. Interestingly, those patients with diabetes mellitus treated with conservative therapy had a greater tendency to become infected over those treated with open reduction internal fixation (ORIF). This study concluded that the diabetic patients who were poorly compliant and had evidence of neuropathy and severe edema are very difficult to manage.7 Key Considerations For Treating Patients With Diabetes Indeed, it is important to emphasize tight metabolic control for patients with diabetes mellitus who sustain the ankle fractures. Beam, et. al., studied the effects of blood glucose control on fracture healing. This study demonstrated decreased bone formation and mechanical stiffness in patients with poorly controlled diabetes mellitus. However, when blood glucose levels were tightly controlled with insulin, the fracture healing was similar to the non-diabetic controls. They concluded that insulin treatment with improved blood glucose control will ameliorate early and late complications of fracture healing in patients with diabetes mellitus.8 From a medical/legal standpoint, it is important to document and enter into the chart any objective assessment that has established that these patients have diabetic neuropathy. Informed consent is also very important in this group of patients, whether one is treating them in the emergency department or the clinic. One should educate these patients about potential complications that might ensue following operative or nonoperative care. Complications may include the development of a Charcot process, severe deformity and potential limb loss. A Pertinent Review Of Conservative Care Options Given these risk factors and treatment considerations in this patient population, clinicians may want to review conservative treatment options. Conservative care for these patients should include an extensive period of non-weightbearing. Ideally, one should emphasize a non-weightbearing period that is twice as long for these patients as opposed to a non-diabetic patient with an ankle fracture. In other words, if a patient with diabetes sustains a non-displaced supination-external rotation fracture that requires six weeks of non-weightbearing in a non-diabetic, then he or she should wear a non-weightbearing, short-leg cast for 12 weeks. It is also recommended to utilize casts that are very well padded or a total contact cast. One must emphasize protection for any osseous prominences in areas that are predisposed to irritation or breakdown. Additionally, frequent cast changes are recommended so clinicians may regularly inspect these areas. This facilitates early diagnosis and treatment of any iatrogenic wounds. One should also instruct the patient to protect the contralateral extremity while he or she is wearing the cast. It is recommended to wrap the contralateral limb lightly in an elastic bandage up to the knee and utilize a pillow in between the legs during sleep. This helps avoid the development of iatrogenic wounds on the contralateral extremity. We also recommend limiting activity in order to avoid problems in the contralateral extremity that are secondary to excess weightbearing or overuse. We have considered prophylactic bisphosphonate therapy in diabetic patients with established neuropathy when they have sustained ankle fractures. Bisphosphonates are bone metabolism regulators that inhibit osteoclastic activity and bone resorption.

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