An excellent and comprehensive review of this topic was published by Wukich (2008).
The risks of treating ankle fractures in diabetics are higher than in non-diabetics whether surgical or closed methods are used (Flynn et al 2000). Infection and skin breakdown are the main problems, and peripheral vascular disease, neuropathy and swelling increase the risk. The risk of wound failure after ORIF has been reported at 30-50%. In open fractures the wound complication rate is 60% and the risk of amputation may be as high as 40% (White et al 2003). RCTs would be needed to accurately assess the risk/benefit ratio of ORIF in displaced fractures in diabetics, but it would be difficult to do such a trial because of the heterogeneity of the patients and fracture patterns.
Most authors recommend 12 weeks of casting in neuropathic patients whether surgical or non-surgical treatment is used, with 6-12 weeks NWB depending on the severity of the injury and the presence of adverse factors. There is no clear evidence to support this, but until clearer evidence emerges prolonged protection, even in relatively low-risk patients, is probably best.
In addition a fracture of the ankle may precipitate Charcot arthropathy in diabetics with peripheral neuropathy (Kristiansen 1980,Thompson 1993, Holmes 1994, Connolly et al 1998). In high-risk neuropathic fractures trans-articular fixation (Jani et al 2004) may give better stability than traditional osteosynthesis.
As in treating any foot and ankle problems in diabetics, it is extremely important to assess the severity and control of the diabetic condition and the presence of peripheral vascular disease, neuropathy, cardiac and renal failure. At the moment it seems reasonable to treat fractures in non-neuropathic patients on the same principles as the general population, but warning of increased risks, protecting for longer and monitoring for late displacement (Wukich 2008). In neuropathic patients we would consider treating displaced fractures with retrograde nails.