A Retrospective Review of Bimalleolar and Trimalleolar Ankle Fractures Staged with External Fixators vs Splinting

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Ankle fractures are the most common lower extremity fracture. Types of ankle fractures include medial, lateral, or posterior malleolus fractures and, in high-energy traumatic fractures, it is common to see bimalleolar and trimalleolar fractures. In the high-energy traumatic cases of bimalleolar and trimalleolar fractures, displacement is common, often requiring preliminary stabilization through external fixation or splinting. External fixation provides improved articular realignment and soft tissue recovery; splinting is less invasive, reducing the risk of infection. While the guidelines for definitive fixation are well-defined, guidelines for preliminary stabilization with external fixators or splints continue to vary. This study aims to provide an evidence-based guide for the preliminary stabilization of bimalleolar and trimalleolar fractures, focusing on improving postoperative outcomes. Methods: 716 patients with bimalleolar or trimalleolar ankle fractures, who were splinted or externally fixed prior to definitive fixation, were retrospectively analyzed to determine if the type of preliminary stabilization altered postoperative outcomes. Patients were divided into cohorts by preoperative fixation (splint vs. external fixation) and fracture classification. Fractures were grouped into four categories: open bimalleolar, closed bimalleolar, open trimalleolar, and closed trimalleolar. These groups were analyzed against multiple variables such as long-term complications (nonunion, malunion, hardware failure), infections, and days from injury to definitive fixation. The results were analyzed using T-test and X2. Results: 716 bimalleolar or trimalleolar ankle fractures were provisionally splinted (n=535) or externally fixated (n=181). On initial presentation, 11% had polytraumatic injuries, of which 19% were externally fixed and 8% were splinted. The overall complication rate was found to be 13% (n=96), of which 24% (n=43) were externally fixed and 10% (n=53) were splinted. There was a significant difference between the external fixation and splint group for infection (P = 0.023), complications (P < 0.0001), hospital stay (P < .0001), and time to definitive fixation (P < .0001). Complications included infection, nonunion, malunion, delayed union, and hardware failure. The most frequent complication was infection (n=52), of which 11% (n=20) were externally fixated, and 6% (n=32) were splinted. Conclusion: We found that compared to the splint group, the external fixation group had higher rates of long-term complications (nonunion, malunion, hardware failure) and infections. Patients in the external fixation group also had increased time until definitive fixation and a longer hospital course, which we suspect to be a contributing factor to the observed higher postoperative complication rates. This study provides evidence supporting using splints over external fixation, when indicated, for preliminary stabilization of ankle fractures. Based on our data, splinting for preliminary stabilization may reduce hospital turnaround times and minimize postoperative complications for bimalleolar and trimalleolar ankle fracture patients.