Shorter Casting Period May Be Sufficient For Many Ankle Fractures

MedicalResearch.com Interview with:

Tero Kortekangas, MD, PhD Orthopaedic trauma surgeon Oulu University Hospital Oulu, Finland

Dr. Kortekangas

Tero Kortekangas, MD, PhD
Orthopaedic trauma surgeon
Oulu University Hospital
Oulu, Finland

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Isolated, stable, Weber B type fibula fracture is by far the most common type of ankle fracture. Traditionally these fractures are treated with below the knee cast for six weeks. Although the clinical outcome of this treatment strategy has been shown to be generally favourable, prolonged cast immobilisation is associated with increased risk of adverse effects, prompting attempts to streamline the treatment. However, perhaps because of absence of high quality evidence on the effectiveness and safety of more simple non-operative treatment strategies, the current tenet of six weeks of cast immobilisation still remains the “gold standard” treatment of stable Weber B type fractures.

MedicalResearch.com: What types of ankle fractures may be amenable to this shorter casting?

Response: Isolated, stable, Weber B-type fibula fractures when the stability of the fracture is confirmed using external-rotation stress test performed under fluoroscopy. These represent roughly half of all Weber B type fractures.

MedicalResearch.com: What are the main findings? 

Response: Three-week immobilization in either a cast or an orthosis was noninferior to traditional six-week cast immobilization in the treatment of a stable Weber B -type fibula fracture, with no excess harms.                                                         

MedicalResearch.com: What should readers take away from your report? 

Response: The duration of immobilisation for stable Weber B type fibula fracture can safely be shortened from six to three weeks, and immobilization can be implemented even with a simple orthosis instead of a cast.

As we have also heard people saying that these findings are not applicable to their practice, as they don’t use external rotation stress testing at the emergency to diagnose or rule out instability of the fracture, we would like to challenge them to think that maybe they should? In essence, by doing this simple test, one can save quite a large number of patients from having to undergo surgery! 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: One very interesting question to study in the future is whether Weber B -type fibula fractures that are found unstable in the external rotation stress test truly require surgery or could we still treat them successfully non-operatively despite the “instability” in ER stress testing?

MedicalResearch.com: Is there anything else you would like to add?

Response: By implementing external-rotation stress test to the standard treatment algorithm for unimalleolar fibula fractures, one can treat a considerable number of patients non-operatively and for those, repeated follow-up radiographs are unnecessary.

Citation:

Kortekangas Tero, Haapasalo Heidi, Flinkkilä Tapio, Ohtonen Pasi, Nortunen Simo, Laine Heikki-Jussiet al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial BMJ 2019; 364 :k5432 

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