Ankle fractures are increasingly an elderly osteoporotic injury (Kannus 2002). They are more likely to have a stable configuration, especially in women (Fox et al 2005), and undisplaced fractures can be treated in the same way as in younger patients.
Displaced fractures require reduction and stabilisation. Makwana et al (2001) showed a small advan- tage for ORIF over closed casting in the over-55 age group. However, bone stock in elderly patients may be poor and stable fixation difficult to achieve. Four techniques can be useful in very porotic bone:
- Malleolar contoured locking plates (Zahn 2012)
- Screws purchasing not only two fibular cortices but both tibial cortices in addition
- Trans-articular fixation with an external fixator, wires or a retrograde nail
- Fibular nailing (Rajeev 2011)
Relative stability may have to be accepted and protected with a BK cast post-operatively. Nevertheless, good results can be obtained (Srinivasan 2001, Shivarathre 2011, Little 2013).
As an alternative to plating the lateral malleolus, fibular nailing has been described (Gehl 2004, Rajeev 2011). Results were probably comparable with those of plating, possibly with fewer wound complications. An RCT comparing nailing and plating in the elderly would be useful.