Comparison of below knee cast and elasticated support bandage treatment for an isolated fracture of the lateral malleolus

Introduction: Ankle fractures are the most common type of fractures treated in orthopaedics with isolated malleolar fractures, accounting for two-thirds of fractures. The most common injury mechanism is supination external rotation, which accounts for the majority of all ankle fracture without a medial side injury, which responds well to non-operative treatment as it is a stable fracture. in the patient with isolated lateral malleolus fracture (Lauge-Hansen supinationeversion external stage II.) Method: A prospective comparative study was carried out in the Department of Orthopaedics in Bir Hospital from February 2007 to January 2009. Patients with ankle fracture were initially treated by below knee posterior slab for seven days to allow the swelling to subside and on seventh day followup they were grouped in two groups. Group A were patients with below knee cast and Group B were elasticated support bandage. Both groups were followed-up in the 5 week for cast or elasticated at 6 month. Result: Of the 48 cases enrolled, the mean age of the patients was 38.85 years. The common mode of Olerud and Molander (1984) was found more in group B in comparison to group A in all follow ups. In initial three successive follow ups at 6 week, 12 week and at 3 month subjective score was . 6 month follow up. The Conclusion: Both below knee cast and elasticated support bandage treatment methods are safe, satisfactory and equally effective with a better early result in elasticated support bandage. Supination external rotation stage II type fracture can be treated conservatively, if there is no medial tenderness.


Introduction
Ankle joint is a complex, three-bone joint.It consists ligamentous structures and distal projections from the form the malleoli.Normally, the ankle joint has 15-20   This motion is essential for normal function and anything that reduces this motion will limit function of the entire foot-ankle complex.It is not a true hinge joint and is a highly congruent saddle shaped joint.
Ankle fractures are the most common type of fractures treated in orthopaedics and the incidence has been constantly increasing in both young active and elderly population. 4Overall, most ankle fractures are isolated malleolar fractures, accounting for two-thirds of fractures, with bimalleolar fractures occurring in one-fourth of the patients and trimalleolar fractures occurring in the remaining 7%.Open fractures are rare accounting for just 2% of all ankle fractures.The overall estimated incidence of ankle fractures is 100 fractures per 10 5 populations in a year.known and widely used for ankle fractures.The Laugeresults of treatment because it accurately describes the in deciding on the appropriate form of treatment.
The most common injury mechanism is supination external rotation, which accounts for the majority of all ankle fracture patterns.In a study from Denmark, Supination External Rotation stage II fractures made up 58% of all supination external rotation fractures.Lauge-Hansen Supination External Rotation stage II fractures comprises upto 40% of all ankle fractures.The injury proceeds externally, sequentially involving the lateral malleolus or the deltoid ligament.Supination External Rotation stage II is the classic short oblique fracture of the well to non-operative treatment as it is a stable fracture. 2ong term clinical follow up studies of closed treatment of Supination External Rotation stage II fracture reported 90% to 98% good functional results, even with 3mm of similar to that of closed treatment in Supination External Rotation stage II injuries.
Biomechanical studies in an axially loaded ankle model disruption of the anterior and posterior syndesmosis, in absence of a medial side injury the talus remains stable and centered in the mortise.Isolated fracture of lateral malleolus does not disturb joint kinematics or cause talar displacement with axial loading. 1 Non-operative method is cost effective and has no difference in long term follow up as compared to operative treatment.A comparative study between protected weightbearing in a walking cast versus elasticated bandage would help avoid unnecessary use of cast and further decrease cost of the treatment.

Methods
Forty eight patients who attended outpatient departments of Bir hospital, Shree Birendra Army hospital and Patan hospital with supination external rotation stage II fractures were assigned to the study from February 2007 to January 2009.This was the sample size intended in the beginning by considering the incidence of the particular cases in the institutions in earlier years.Approval from ethical board of National Academy of Medical Sciences and informed consent from each patient was taken before the study.
The criteria for entry were skeletally mature patients <65 years who presented with isolated fractures of the lateral malleolus Lauge-Hansen Supination-External Rotation Stage II.Patients were excluded if they had medial tenderness or associated medal malleolus fracture, skeletally immature patients, pathological fractures, associated injuries to the foot ankle, tibia or knee, open fractures, associated neurovascular injury in the affected limb, who had had previous ankle trauma, patients using walking aids and pregnancy.
The standard radiographic evaluation of the ankle included anteroposterior, lateral and mortise views.A number of radiographic measurements can be made from these views and, if necessary, compared with the opposite side.These parameters provide an objective measurement of instability and are useful not only in diagnosis but also in planning treatment.
initially by the application of a below knee back slab and the patients were reviewed in outpatient department 24 hours after injury to check any plaster related complications.Patients were advised to elevate the ankle for swelling to subside and were followed up after 7 days.Check x-ray that fracture displacement was unlikely when the affected

JSSN Journal of Society of Surgeons of Nepal
JSSN 2014; 17 (2)   limb was protected by a below knee slab and restriction of weight bearing.
They were then allocated to one of two treatment group according to the predetermined randomized schedule.One group had a full plaster cast applied below the knee when the soft tissue swelling subsided.This group was called treatment 'A' group.Second group was given an elasticated support bandage and had early mobilization with the help of physiotherapy.This group was called treatment 'B' group.First case was included in group A, second case was included in group B, third case was again included in group A, fourth case was group B, so on and so forth alternating.
All forty eight patients were treated according to a standard protocol consisting of the use of non-steroidal antirequired and crutches for pain relief and were encouraged to bear weight as soon as possible.All patients were reviewed in an outpatient department one week after removal of cast or elasticated bandage and followed up at monthly standard radiographic evaluation of the ankle included anteroposterior, lateral and mortise views which were taken after the removal of cast or elasticated bandage to asses fracture healing.All patients were also asked to visit as early as possible if plaster related complications appeared.subjective ankle scoring system of Olerud and Molander  (1984).Pain was measured using a Visual Analogue Scale (VAS) and the days of analgesic required were recorded.Range of motion was recorded by the help of goniometer and was compared to the normal ankle.Early sign of union in radiology was considered when trabeculae was seen traversing the fracture site and there was loss of gap in the fracture site.
The selected data were analyzed with the help of Statistical Package for Social Sciences using student't' test for continuous variables and with Chi-square test for categorical

Results
Forty-eight patients were included, among them twenty-Group B. Two patients in Group A had swelling in the postslab even after one week and were excluded from study and one patient in the same group did not come in follow-up.
subsequent follow-ups and were excluded from the study.Therefore, 40 patients were included in the treatment phase of the study.Twelve women and eight men with an average age of 40.5years were in a full plaster cast applied below the knee and eleven women and nine men with an average age of 37.2 years were in elasticated support bandage.The statistically.Most of the patients attended in hospital on the same day of injury (26 patients) while rest came the next day of injury.The mode of injury was mainly fall from height (28 out of 40 patients).The complaints of the patients were pain, swelling and the inability to bear weight.Remaining 12 patients had other minor associated injuries which did not require any intervention and did not hamper for the requirements of the protocol.
The subjective score was found more in group B in comparison to group A in all follow ups.In initial three successive follow ups at 6 week, 12 week and at 3 month p values of 0.00, 0.00 and 0.011 respectively.(Table 1 & Figure 1) However, subjective score was found statistically    articulation is commonly normal, which is to be expected unaffected by this injury.
Clinical studies have consistently failed to show any difference in outcome between fractures treated operatively and those managed non-operatively and similar outcomes have been observed in other studies as well.Similarly, total range of motion of ankle in elasticated to group A. But the difference was gradually decreased in successive follow-ups which might be due to improvement in range of motion exercises in ankle joint treated by plaster immobilization after removal of the cast.So, at the end of 6 months, there was no difference in range of motion in both Similar study conducted by A.M Port et al showed minimal difference between these two groups which was interpretation.This also supports that the motion improved due to improvement in range of motion exercises in ankle joint treated by plaster immobilization after removal of the cast as in immobilization group.
The patient in Group A required less analgesic as compared to Group B. The reason might be due to immobilization of the ankle which caused less pain and less analgesic.But the difference between two groups was statistically not with plaster immobilization group and elasticated support bandaged group. 20Clinically none of the patients in both the groups had tenderness at fracture site at the end of 6 months.However, another study found that the mean VAS 20

Conclusion
Lauge-Hansen Supination External Rotation stage II ankle fracture is a stable fracture.Both below knee cast and elasticated support bandage treatment methods are safe, satisfactory and equally effective with a better early result in elasticated support bandage as compared to plaster group.However both treatments show equally good subjective, objective and functional outcome later.

Figure 1 :
Figure 1: Mean Functional Score according to Olerud & Molander Similarly, visual analogue pain score (Figure 2) recorded in group B in comparison to group A in all follow ups.Immobilized group required less analgesic but the

Figure 3 :
Figure 3: Total Loss of Range of Motion

Table 1 : Subjective Scores at the follow ups
11, Supination External Rotation stage II fractures are benign injuries and can be treated by close method without reduction.11improveddue to early range of motion of the ankle joint treated by elasticated support bandage in contrast to the effect of immobilization of the ankle by plaster in group A. But the difference was gradually decreased in the end of 6 months which might be due to improvement in range of motion exercises in ankle joint treated by plaster immobilization after removal of the cast.There is ankle in patients treated with functional brace.