A Call for Fewer Casts on Kids’ Ankle Injuries

March 3, 2016 in STSMPT

A study published earlier this year in the Journal of the American Medical Association Pediatrics concludes that the way many healthcare professionals were trained to identify an ankle fracture is wrong and that many casts were probably more detrimental than beneficial. Ankle injuries send more than 2 million North Americans to the doctor each year. The researchers report that, for half a century, healthcare providers have been trained to presumptively diagnose tenderness overlying the bony prominence at the outside of the ankle as a Salter-Harris I fracture (SH1DF) – even when a fracture cannot be seen on x-ray. This approach appears to have led to many children receiving an immobilizing cast for a month or two when a removable brace may have sufficed.


The researchers found that only 3% of children who might normally have been diagnosed with an SH1DF ankle fracture actually had that fracture. These were children who presented to an emergency department with an ankle injury, unable to bear full weight on the ankle, and having pain and tenderness on the outside of the ankle (specifically over the physis of the distal fibula). It turns out that 80% of the children had ligament injuries – most of which were intermediate to high grade. In these cases, an immobilizing cast is not necessary. A removable brace can provide adequate protection if any sort of limited range of motion is needed. Aside from the increased costs involved, treating a sprain as a fracture can prove detrimental to full recovery.


One of the biggest problems with ankle sprains is chronicity and recurrence. Up to 64% of conventionally treated ankle sprains create persisting symptoms after three years and recurrence rates have been reported as high as 53%. Immobilization impedes ankle sprain healing. Early mobilization has proven more likely to prevent future sprains. Functional stress stimulates the incorporation of stronger replacement collagen. The sooner appropriate motion is introduced into the healing process, the more organized and functional the tissue repairs will be. Of course, consultation and guidance from a suitably trained professional can be helpful for assessing what is the right amount of movement for each individual injury. Professional-grade, acute ankle rehabilitation will include at least three elements: (1) manual therapy / passive joint motion; (2) exercise therapy for strengthening and stretching; and (3) neurological / proprioceptive retraining for balance and reaction times.


This new study suggests strongly that if a child injures his or her ankle, pain is on the outside of the ankle, and no fracture is evident on x-ray, there is only a 3% chance it’s a fracture and an 80% chance it’s a sprain. Undisplaced Salter-Harris fractures of the ankle can be confirmed by MRI. The immobilization common to fracture treatment is exactly the wrong thing to do for an ankle sprain, and it costs more.

Ankle Injuries Casts

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