Immobilisation of stable ankle fractures
Date First Published:
March 10, 2004
Last Updated:
July 24, 2013
Report by:
Anna J Thackray, Jonathan Taylor , CT3 EM, CT3 EM, (Manchester Royal Infirmary )
Search checked by:
Charlotte E Cross , Manchester Royal Infirmary
Three-Part Question:
In [adults and children with low risk distal fibular fractures] is [a functional brace better than plaster cast immobilisation] at [improving functionality and reducing time to recovery]
Clinical Scenario:
A young, independently mobile female attends the Emergency Department following a fall. X-ray reveals a Weber A fracture of the lateral malleolus. She is reluctant to have a plaster cast and you wonder if a removable functional brace would be as effective
Search Strategy:
Medline 1946 to February Week 4 using the OVID interface
Search Details:
([exp Fractures, bone/] AND [exp Ankle injuries/] AND [exp Orthotic devices/ OR exp Braces/ OR exp Casts, surgical/ OR cast.mp/ OR fibreglass.mp/ OR plaster.mp/]) LIMIT to human and English language
Outcome:
260 papers found of which 5 were useful
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures. Stuart P R, Brumby C, Smith S R. 1989, UK | 40 adult patients with supination-eversiontype II fractures. Random allocation to below knee walking plaster or AirCast brace |
Prospective randomised study | Comfort at 24hrs | Brace better than cast (p<0.05) | Small sample size. |
| Post fracture swelling | Brace better than cast (p<0.00001) | ||||
| Time to union | No significant difference | ||||
| Movement at union | Brace better than cast (p<0.00001) | ||||
| Symptoms at 3 months | Brace better than cast (p<0.05) | ||||
| Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus. Port A M, McVie J L, Naylor G et al. 1996, UK | 65 adult patients with stable lateral maleolus (Weber B1) fractures. Assigned to below knee plaster or elasticated support by treating orthopaedic surgeon |
Prospective observational study | Pain (visual analogue score) | No significant difference (0.6 ±0.4 in support vs 1.6 ±0.4 in plaster) | No randomisation or blinding of allocation. All patients spent the 1st 24hrs in below knee cast from ED. No intention to treat analysis. Large female predisposition to treatment in plaster. |
| Function at 1 month | 60 in support vs 50 in plaster (p<0.001) | ||||
| Function at 2 month | 80 in support vs 70 in plaster (p<0.01) | ||||
| Function at 3 month | 89 in support vs 77 in plaster (p<0.05) | ||||
| Function at 6 month | 93 in support vs 89 in plaster (No significant difference) | ||||
| A randomised, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Boutis K, Willan A R, Babyn P, et al. 2007, Canada | 111 children aged 5 to 15 with acute symptomatic low risk ankle fracture. Randomised to receive fibreglass cast or AirCast brace |
Single blind, noninferiority RCT | Function at 4 months | 91.3% in brace vs 85.3% in plaster (p<0.0001) | All patients kept non-weight bearing for 1st 5 days. Salter-Harris type I fractures included based on clinical findings alone. |
| Patient satisfaction | 52.8% in brace vs 18% in plaster ‘very satisfied’ (p<0.0001) | ||||
| Cost effectiveness | Brace cheaper than cast (p<0.0001, cost effectiveness accebtibility curve >80%) | ||||
| A prospective study comparing attempted weight bearing in fibreglass below-knee casts and prefabricated pneumatic braces. Mason L W, Dodds A. 2010, UK | 117 patients with metatarsal or stable ankle fracture and able to weight-bear. Assigned to treatment with fibreglass cast or AirCast brace |
Observational study | Ability to weight-bear at 48hrs | 65.85% in brace vs 42.48% in plaster (p<0.001) | No blinding or randomisation (choice based on clinician preference). No evaluation of significance of results or follow up |
| Functional outcome after air-stirrup ankle brace or fibreglass backslab for pediatric low-risk fractures. Barnett P L J, Lee M H, Oh L, et al. 2010, UK | 45 children aged 5 to 15 with acute symptomatic low risk ankle fracture. Randomised to receive fibreglass posterior splint or AirCast brace |
Single blind, noninferiority RCT | Function at baseline | No significant difference (p=0.39) | Underpowered due to poor recruitment and small sample size. |
| Function at 2 weeks | No significant difference (p=0.26) | ||||
| Function at 4 weeks | No significant difference (p=0.13) |
Author Commentary:
5 studies of varying quality build on the existing evidence base that using a functional brace postoperatively in ankle fractures to support the use of such devices in stable Weber A or B1 ankle fractures. The findings show that a functional brace is at least as good as, if not better than, immobilisation in plaster in all measured outcomes.
Bottom Line:
The currently available evidence is based on small numbers and observational studies, but a functional brace is shown to give more favourable outcomes and should be considered on an individual basis. Larger studies of good quality are needed to answer this specific question.
References:
- Stuart P R, Brumby C, Smith S R. . Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures.
- Port A M, McVie J L, Naylor G et al. . Comparison of two conservative methods of treating an isolated fracture of the lateral malleolus.
- Boutis K, Willan A R, Babyn P, et al.. A randomised, controlled trial of a removable brace versus casting in children with low-risk ankle fractures.
- Mason L W, Dodds A.. A prospective study comparing attempted weight bearing in fibreglass below-knee casts and prefabricated pneumatic braces.
- Barnett P L J, Lee M H, Oh L, et al. . Functional outcome after air-stirrup ankle brace or fibreglass backslab for pediatric low-risk fractures.