COCHRANE NURSING CARE REVIEW

Surgical Versus Conservative Interventions

for Treating Ankle Fractures in Adults
Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM
QUESTION: WHAT ARE the effects of surgical
versus conservative interventions for treating
ankle fractures in adults?

Significance to Nursing
It is estimated that on an annual basis, one in every
800 people experience an ankle fracture. Ankle
fractures can be treated conservatively (nonsurgical treatment) or surgically. Conservative treatment involves repositioning of the fractured bone
by manipulating it through the intact skin, followed
by immobilization of the ankle in a plaster or synthetic cast for several weeks. Surgical treatment includes open reduction of the fracture (if displaced)
and fixation with wires, pins, screws, and plates.
After surgery, patients may be placed in a cast.
The surgical treatment aims to provide anatomic
restoration and immediate stability, which facilitates earlier mobilization. However, all surgery
carries risk of complications, such as surgical site
infection, implant or fixation failure, and the possibility for reoperation.
In current practice, ankle fractures are classified
according to three different classification systems,
and treatment often depends on the type of
fracture. Some clinicians believe that conservative
treatment is adequate for ankle fractures, but others

Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM, is the

Director and Chief Nurse Researcher, Department of Nursing,
Institute for Nursing Excellence, UCSF Medical Center, San
Francisco, CA, and a member of the Cochrane Nursing Care
Field (CNCF).
Conflict of Interest: None to report.
This is a summary of a Cochrane Review. The full citation
and the names of the researchers who conducted the review
are listed in the Reference section.
Address correspondence to Daphne Stannard, UCSF Institute
for Nursing Excellence, 2233 Post St., Ste. 201, San Francisco,
CA 94115; e-mail address: Daphne.Stannard@ucsfmedctr.org.
2014 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2013.12.001

138

consider surgical treatment necessary to prevent

predisposition for post-traumatic osteoarthritis.
This review aimed to ascertain whether surgery
or conservative treatment provides a better longterm outcome for people with ankle fractures.

Study Description and Results

Three randomized controlled trials (RCTs) and one
quasi-RCT, a total of 292 adult participants with
ankle fractures, were included in the review. All
four trials compared open reduction and internal
fixation (ORIF) versus closed reduction and plaster
cast immobilization (conservative treatment). One
of the RCTs was conducted in two hospitals in Sweden (111 patients) and compared ORIF (followed
by bed rest for 5 days, partial weight bearing
from 6 weeks, and full weight bearing at 9 weeks)
versus closed reduction and a plaster cast for
6 weeks (followed by partial weight bearing from
6 weeks and full weight bearing at 9 weeks). The
second RCT was conducted in the United Kingdom
(43 patients) and compared ORIF followed by a
below-knee plaster cast for 6 weeks with protected
weight bearing versus closed reduction followed
by a below-knee plaster cast for 6 weeks with protected weight bearing. The third RCT was conducted in the United States (96 patients). In this trial, all
participants had a satisfactory closed reduction
before randomization to ORIF (followed by a
below-knee plaster for 1 week; walking on
crutches without weight bearing started a few
days after surgery and until week 10) versus a
long-leg plaster cast for 6 weeks without weight
bearing and a below-knee for 4 additional weeks.
The quasi-RCT was conducted in the United
Kingdom (42 patients) and compared ORIF (followed by a below-knee backslab and active ankle
movement for up to 5 days and then a plaster cast
for 6 weeks) versus closed reduction and a longleg plaster cast for 6 weeks. Primary outcome measures were functional outcome, pain, and major
adverse events. Preference was given to validated
outcome measures, such as visual analogue scale

Journal of PeriAnesthesia Nursing, Vol 29, No 2 (April), 2014: pp 138-139

COCHRANE NURSING CARE REVIEW

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ratings for pain. Secondary outcomes included the

following:
 Measures of recovery such as time to resume
normal activities or return to work,
 Range of motion,
 Measures of functional impairment, and
 Radiologically defined osteoarthritis
Length of follow-up varied across studies and
ranged between 20 weeks and 7 years. All studies
were at high risk of bias from lack of blinding.
Additionally, loss to follow-up or inappropriate
exclusion of participants put two trials at risk of
attrition bias. Because of the high level of missing
data, all authors were contacted for additional information. The trials used different and incompatible outcome measures for assessing function and
pain, so a limited meta-analysis was possible only
for early treatment failure, some adverse events,
and radiological signs of arthritis.
Summary of main results:
 The Swedish RCT, following up on 92 of 111
randomized participants, found no statistically
significant differences between surgery and
conservative treatment in patient-reported
symptoms (11/43 vs 14/49; risk ratio [RR],
0.90; 95% confidence interval [CI], 0.46-1.76)
or walking difficulties at 7-year follow-up.
 The UK RCT, reporting data for 31 of 43 randomized participants, found a statistically
significant better mean functional outcome
score using a physician-completed validated
tool in the surgically treated group. There
was no difference, however, between the

two groups in pain scores after a mean

follow-up of 27 months.
 The US RCT, reporting data for 49 of 96 randomized participants at 3.5-year follow-up,
found no difference between the two groups
using a nonvalidated clinical score.
 The quasi-RCT study from the United
Kingdom, reporting data for 40 participants
at 20 weeks follow-up, found no statistically
significant differences between the two
groups regarding restriction of dorsiflexion
or abnormal foot angle.
 Early treatment failure, generally reflecting
the failure of closed reduction and leading
to surgery in patients allocated conservative
treatment, was significantly higher in the conservative treatment group (2/116 vs 19/129;
RR, 0.18; 95% CI, 0.06-0.54). It should be
noted, however, that two trials did not report
this criteria. Otherwise, there were no statistically significant differences between the
two groups in any of the reported complications. For example, pooled results from two
trials of participants with radiological signs
of osteoarthritis at averages of 3.5- and 7year follow-up showed no between-group differences (44/66 vs 50/75; RR, 1.05; 95% CI,
0.83-1.31).

Nursing Implications
There is insufficient evidence to conclude whether
surgical or conservative treatment produces superior long-term outcomes for ankle fractures in
adults.1

Reference
1. Donken CCMA, Al-Khateeb H, Verhofstad MHJ, van
Laarhoven CJHM. Surgical versus conservative interventions
for treating ankle fractures in adults. Cochrane Database Syst

Rev;CD008470, http://dx.doi.org/10.1002/14651858.CD0084
70.pub2; 2012.