The closed treatment of severe malleolar fractures.

The authors studied, with clinical and radiological criteria the results of closed treatment (reduction by manipulation and immobilization in a plaster cast for 7 or 8 weeks) of severe displaced malleolar fractures. Of 145 patients who had suffered an ankle fracture and were treated with closed methods between 1979 and 1989, 78 were reviewed, with an average follow-up of 6.2 years. The main difficulties of closed treatment concerned reduction of the fractures; anatomical reduction was achieved only in 32.4% of the cases, and deterioration of the position achieved often occurred (26.2%). Although some joints healed in a fair position, subjective and objective late results were excellent or good in 77% of the cases, fair in 20.5% and poor in 2.6%. The most common clinical outcome was a slight decrease of the range of motion in the injured ankle, which was found in 68% of the cases. Arthritis developed in 28.2% of the reviewed ankles, both after an initial good reduction as well as after an initial poor reduction. A complete failure of closed treatment occurred in 8.3% of the cases, caused by an interpositioning of soft tissues among bone fragments leading to unsuccessful manipulation or by late deterioration of the initial position of reduction causing healing of the fracture in a poor position (severe talar shift).