The effect of massage on the plantar flexor muscles during the fixation period in postoperative patients with an ankle fracture.

INTRODUCTION: Ankle fractures are one of the most common lower extremity fractures. After surgery, the ankle joint is often immobilized in a plantar flexion position, and there have been many reported cases of limited ankle joint range of motion. Therefore, the purpose of the present study was to investigate the effect of regular massage interventions on ankle joint range of motion after removal of fixation. METHODS: The massage group comprised 30 patients who had sustained an ankle fracture and had undergone surgical fixation, physical therapy, and massage between November 2020 and March 2022. These subjects received a 3-min massage twice daily, five times a week. The control group consisted of 38 patients who had sustained an ankle fracture between January 2015 and September 2020 and had undergone surgical fixation as well as regular physical therapy. RESULTS: The respective ankle dorsiflexion and plantarflexion ranges of motion after cast removal were 2.50 ± 7.2° and 42.3 ± 7.2° in the massage group and -8.62 ± 2.9° and 34.8 ± 8.3° in the control group. An unpaired t-test showed that the ankle dorsiflexion and plantarflexion ranges of motion in the massage group were significantly greater than those in the control group (p = 0.036 and p < 0.01). CONCLUSIONS: Our results indicate that regular 3-min massage interventions of the plantar flexors could prevent the progression of a range of motion limitations in postoperative patients with an ankle fracture more effectively than regular physical therapy alone.

Management of Pain Associated with Fractures.

PURPOSE OF REVIEW: The purpose is to review current literature on pain management strategies from initial presentation to postoperative care on common fracture types. RECENT FINDINGS: - Hip fractures benefit from use of multimodal pain control for early mobility and decreased narcotic requirement. - Distal radius fracture pain during reduction can be managed with hematoma block. Postoperatively, a soft dressing is adequate, and use of a compression glove may improve pain control and edema. - Ankle fractures can be reduced with hematoma block, though use of procedural sedation may reduce reduction attempts for fracture dislocations. - Long bone fracture pain management is trending toward multimodal pain control. Though there is no high-quality evidence, concern that regional anesthesia may mask compartment syndrome has limited its use in high-risk fractures. - The effect of NSAIDs on bone healing has not been conclusively demonstrated. The literature is still inconclusive regarding superiority of either spinal or general anesthesia during operative treatment. Fracture pain control is complex and multifactorial, requiring nuanced clinical judgment in the face of mixed clinical findings.

Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures.

BACKGROUND: Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. METHODS: A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. RESULTS: The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. CONCLUSION: Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Early motion and directed exercise (EMADE) versus usual care post ankle fracture fixation: study protocol for a pragmatic randomised controlled trial.

BACKGROUND: Following surgical fixation of ankle fractures, the traditional management has included immobilisation for 6 weeks in a below-knee cast. However, this can lead to disuse atrophy of the affected leg and joint stiffness. While early rehabilitation from 2 weeks post surgery is viewed as safe, controversy remains regarding its benefits. We will compare the effectiveness of early motion and directed exercise (EMADE) ankle rehabilitation, against usual care, i.e. 6 weeks' immobilisation in a below-knee cast. METHOD/DESIGN: We have designed a pragmatic randomised controlled trial (p-RCT) to compare the EMADE intervention against usual care. We will recruit 144 independently living adult participants, absent of tissue-healing comorbidities, who have undergone surgical stabilisation of isolated Weber B ankle fractures. The EMADE intervention consists of a non-weight-bearing progressive home exercise programme, complemented with manual therapy and education. Usual care consists of immobilisation in a non-weight-bearing below-knee cast. The intervention period is between week 2 and week 6 post surgery. The primary outcome is the Olerud and Molander Ankle Score (OMAS) patient-reported outcome measure (PROM) at 12 weeks post surgery. Secondary PROMs include the EQ-5D-5 L questionnaire, return to work and return to driving, with objective outcomes including ankle range of motion. Analysis will be on an intention-to-treat basis. An economic evaluation will be included. DISCUSSION: The EMADE intervention is a package of care designed to address the detrimental effects of disuse atrophy and joint stiffness. An advantage of the OMAS is the potential of meta-analysis with other designs. Within the economic evaluation, the cost-utility analysis, may be used by commissioners, while the use of patient-relevant outcomes, such as return to work and driving, will ensure that the study remains pertinent to patients and their families. As it is being conducted in the clinical environment, this p-RCT has high external validity. Accordingly, if significant clinical benefits and cost-effectiveness are demonstrated, EMADE should become a worthwhile treatment option. A larger-scale, multicentre trial may be required to influence national guidelines. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN11212729 . Registered retrospectively on 20 March 2017.

Manual Physical Therapy Following Immobilization for Stable Ankle Fracture: A Case Series.

STUDY DESIGN: Case series. BACKGROUND: Ankle fractures commonly result in persistent pain, stiffness, and functional impairments. There is insufficient evidence to favor any particular rehabilitation approach after ankle fracture. The purpose of this case series was to describe an impairment-based manual physical therapy approach to treating patients with conservatively managed ankle fractures. CASE DESCRIPTION: Patients with stable ankle fractures postimmobilization were treated with manual physical therapy and exercise targeted at associated impairments in the lower limb. The primary outcome measure was the Lower Extremity Functional Scale. Secondary outcome measures included the ankle lunge test, numeric pain-rating scale, and global rating of change. Outcome measures were collected at baseline (performed within 7 days of immobilization removal) and at 4 and 12 weeks postbaseline. OUTCOMES: Eleven patients (mean age, 39.6 years; range, 18-64 years; 2 male), after ankle fracture-related immobilization (mean duration, 48 days; range, 21-75 days), were treated for an average of 6.6 sessions (range, 3-10 sessions) over a mean of 46.1 days (range, 13-81 days). Compared to baseline, statistically significant and clinically meaningful improvements were observed in Lower Extremity Functional Scale score (P = .001; mean change, 21.9 points; 95% confidence interval: 10.4, 33.4) and in the ankle lunge test (P = .001; mean change, 7.8 cm; 95% confidence interval: 3.9, 11.7) at 4 weeks. These changes persisted at 12 weeks. DISCUSSION: Statistically significant and clinically meaningful improvements in self-reported function and ankle range of motion were observed at 4 and 12 weeks following treatment with impairment-based manual physical therapy. All patients tolerated treatment well. Results suggest that this approach may have efficacy in this population. LEVEL OF EVIDENCE: Therapy, level 4.