How To Treat Ankle Fractures In Patients With Diabetes
Complications: What The Literature Reveals
When it comes to the surgical management of ankle fractures in patients with diabetes, potential complications include infection, malunion, nonunion and Charcot arthropathy. These complications can be rather difficult to manage and have significant morbidity.
In particular, when one is managing diabetic ankle fractures, the treating physician should have a high index of suspicion for the development of Charcot. The incidence of Charcot arthropathy is relatively high following fracture in patients with diabetes mellitus. There are clearly factors other than mechanical overload that are involved. 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.