How To Treat Ankle Fractures In Patients With Diabetes

By Alan R. Catanzariti, DPM, Robert W. Mendicino, DPM, and Travis L. Sautter, DPM

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. Bisphosphonates are indicated for metabolic bone disease and seem to be well tolerated with very few side effects. The objective with bisphosphonate therapy in diabetic patients with ankle fractures is to limit bony destruction during the acute phase of Charcot. Bisphosphonates have been well established for use in early stage Charcot.9,10 One may consider bisphosphonates as a prophylactic measure in this particular group of patients in order to minimize the incidence of Charcot.

Pertinent Pearls On Managing Open And Unstable Fractures
Open fractures are an especially challenging problem in diabetic patients with established neuropathy. White, et. al., evaluated the treatment of 14 fractures in 13 patients. They achieved complete bony union without complication in only three patients.11
For unstable ankle fractures and significant deformity in patients with diabetes, one should consider surgical management. Surgical options may include ORIF or closed reduction with percutaneous and/or external fixation. As with any type of surgical management, surgeons should emphasize certain precautions. One should allow for a preoperative decrease in edema after the injury before proceeding with surgical treatment. This allows a more healthy soft tissue envelope that might be less prone to soft tissue complications.

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