On ankle fractures

Abstract

Ankle fractures range from simple avulsions to complex injuries and the treatment options are numerous. Sweden has no national guidelines regarding the management and treatment of ankle fractures, leaving these choices up to local tradition or individuals’ decisions. The overall aim of this thesis is to investigate how ankle fractures are classified, managed and treated and analyse the effect of a structured treatment algorithm (TA). The Swedish Fracture Register (SFR) is the platform for all the included studies.

Paper I describes the epidemiology of all 57,433 ankle fractures registered in the SFR between 2012 and 2022. The results demonstrate that women more often sustain ankle fractures and are older than men at the time of injury. Ankle fractures are most frequently caused by a simple same-level fall. There is a pronounced seasonal variation, with a distinct peak during winter, which is driven by simple same-level falls causing B-type fractures. Paper II reveals that the incidence of ankle fractures declined during the first wave of the Covid-19 pandemic. The greatest reduction was seen during the first studied month, March 2020, among women and in the 70 years and older age group. This paper also demonstrates that the SFR can be utilised to compare fracture incidences over time. Paper III investigates how lateral malleolar fractures at the level of the syndesmosis are classified, managed and treated. One key aspect to which fractures that are safe to treat non-surgically is the stability of the fracture and consequently the ankle joint. Stability is dependent on the integrity of the deltoid ligament. Paper III illuminates the difficulties involved in clinically evaluating the deltoid ligament. The results demonstrate the variability that exists in management and treatment decisions, as 30% of the patients were treated surgically and 70% non-surgically, with no clear relationship to the assessment of stability. Paper IV presents the results of a study comparing a group of lateral malleolar ankle fractures at the level of the syndesmosis treated before the introduction of a structured TA with a group managed and treated afterwards. The results show that a TA induced changes in all the studied parameters; reducing the number of radiographic examinations, the number of days immobilised and the proportion of surgical treatment, as well as increasing the number of patients that were allowed full weight-bearing. Paper V is a qualitative interview study with physicians registering fractures in the SFR with the objective of extending knowledge of how a knowledge support system was perceived by users. The results reveal that users appreciate knowledge support, finding that it increases the value for work and the incentive to register fractures during busy working days.

To conclude, ankle fractures predominantly affect women and occur during winter as a result of simple same-level falls. The incidence declined during the Covid-19 pandemic, primarily during the first month, in women and in the 70 years and older age group. Structured TAs can optimise resource consumption in the management and treatment of ankle fractures. The implementation of a TA for ankle fractures was found to reduce the number of unnecessary surgical procedures and make decisions regarding treatment less dependent on the individual surgeon’s discretion. Knowledge support based on a TA incorporated into the SFR provides an appreciated validation of the clinical decisions taken by physicians and was found by the users to increase the value of the care they provided.