| Summary: | Category: Trauma Introduction/Purpose: Acute ankle fracture-dislocations require emergent reduction. Once the dislocation is successfully reduced, the ideal timing of operative fixation is not well understood. At our institution, a protocol enables patients who have a successful closed reduction in the Emergency Department (ED) to go home and return to the clinic to schedule surgery. We sought to describe the rate at which initial reduction is lost between the ED and clinic visits, and to identify factors associated with loss of reduction. Methods: We retrospectively reviewed all patients who were treated operatively for an ankle fracture from 2008-2012 at a single, Level 1 trauma center and identified 30 patients who had isolated, closed ankle fracture-dislocations that were successfully reduced and splinted in the ED. Adequate reduction was defined by achievement of congruent joint line with < 5mm medial clear space. If reduction was maintained at the clinic visit, surgery was scheduled electively, defining a success. However, if reduction was lost in the interim between ED and clinic visits the patient was admitted from clinic for urgent surgical stabilization, defining a failure. Results: Seventeen patients (57%) successfully maintained closed reduction and 13 (43%) experienced failure of closed reduction in the interim. Compared to the successful group, the failed group had significantly greater posterior malleolus (PM) fracture fragment size (5.1 mm vs. 3.0 mm, p = 0.029). When the ratio of PM fracture fragment size to complete articular surface was > 0.1, rate of failure was 65% compared to 18% when the ratio was ≤0.1 (p = 0.016). There were 2 major wound complications, both of which occurred in the group that failed reduction in the interim. Conclusion: Greater PM fracture fragment size is associated with higher rates of interim failure of closed reduction of closed ankle fracture-dislocations. Injuries with a large PM fracture fragment may warrant consideration of earlier operative intervention.
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