The Journal of Diabetic Foot Complications
Open access publishing
Are Isolated, Non-Displaced Medial Malleolus
Fractures Always Benign in Patients with
Diabetes?
Authors:
Wenjay Sung DPM 1, Sherunda Smith, DPM, MPH 2, Dane K. Wukich, MD 3
The Journal of Diabetic Foot Complications, Volume 1, Issue 1, No. 2, © All rights reserved.
C
Abstract: Isolated, non-displaced fractures of
the medial malleolus in diabetic patients are
generally treated non-operatively. The authors
present a case report involving an isolated
non-displaced medial malleolus fracture in a
diabetic patient, the sequelae into acute
Charcot
arthropathy,
and
treatment
recommendations.
A 57 year old female presented to the
emergency department in November 2005
complaining of pain to the left ankle. She had
sustained an isolated, non-displaced medial
malleolus fracture after twisting her ankle while
walking down a flight of three stairs. She was
examined and treated by an orthopaedic resident
and splinted. (Fig. 1) Post-splinting radiographs
revealed excellent anatomic alignment. (Fig. 2)
She was dispensed a walker, instructed to be nonweight bearing, and to follow up in our office the
following week.
Key words: Diabetes, medial malleolus fracture,
acute Charcot arthropathy, deltoid ligament
complex.
I
ase report
ntroduction
Isolated non-displaced medial malleolus ankle
fractures are routinely treated non-operatively.
Patients with diabetic neuropathy are at risk for the
development of, non-union, mal-union, infection,
and Charcot arthropathy.3,14
When she first presented to our office, the splint
was removed and the ankle was grossly unstable.
She also presented with a medial malleolar
ulceration with surrounding erythema. Radiographs
demonstrated an unstable fracture dislocation of the
ankle with significant displacement of the medial
malleolus fracture fragment (Fig. 3). Her skin
temperature was elevated about her ankle, and she
had severe non-pitting edema. Her dorsalis pedis
pulse was palpable, but the posterior tibial pulse
was not, secondary to edema. Subjectively, she had
no complaints of pain or tenderness about her ankle
or foot, She was tested via Semmes-Weinstein
monofilament, revealing a complete absence of
protective sensation and fine point discrimination.
Based on her history and presentation, she was
diagnosed with acute Charcot arthropathy (ACA)
and acute cellulitis.
The purpose of this case report is to present an
isolated non-displaced medial malleolus fracture
that progressed to significantly dislocated, unstable,
trimalleolar ankle fracture with acute Charcot
arthropathy (ACA) over short period of time.
Address correspondence to: Dr. Dane K. Wukich, MD. Assistant Professor
of Orthopaedic Surgery Chief, Division of Foot and Ankle Surgery
Medical Director, UPMC Comprehensive Foot & Ankle Center.
University of Pittsburgh School of Medicine
Pittsburgh, PA 15203, USA. Email: [email protected]
1,2
Resident Physician. UPMC Podiatric Residency Program. 2000 Mary Street
Pittsburgh, PA 15203, USA.
3
Assistant Professor of Orthopaedic Surgery Chief, Division of Foot and
Ankle Surgery. Medical Director, UPMC Comprehensive Foot & Ankle
Center. University of Pittsburgh School of Medicine. Pittsburgh, PA 15203,
USA.
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The Journal of Diabetic Foot Complications
Open access publishing
Figure 1 Patient with diabetes presents to the
emergency department with isolated, non-displaced
medial malleolus fracture.
Figure 3 Radiographs on first visit to our office,
approximately one week after discharge from emergency
department, demonstrating an unstable ankle.
She was admitted to the hospital and intravenous
antibiotic treatment was initiated. The next day, we
performed irrigation and debridement of the medial
ulcer, a percutaneous Achilles tendon lengthening,
closed reduction of the displaced medial fracture
fragment, and applied a multiplane external fixator.
To increase stability, a Steinmann pin was placed
across the ankle joint. (Fig. 4) During the postoperative course, an external bone stimulator was
used to promote osseous healing. The patient was
instructed to remain non-weight bearing on the
affected lower extremity for the next three months.
During that time she was followed closely and
radiographs were obtained. Her cellulitis and ankle
ulceration resolved without incidence.
Figure 2 Post-splinting radiographs reveal the ankle
mortise is reduced anatomically.
Her past medical history included: insulin
dependent diabetes mellitus with severe neuropathy,
hyperlipidemia, coronary artery disease with bypass
grafting, cerebral vascular accidents, metastatic
melanoma, and osteoporosis.
Her medications
included: Humulin ™, Tramadol™, Clonazepam
™, Lipitor™, Neurontin™, Plavix™, and
Citaloprolam™. She denied tobacco use or alcohol
consumption. She had a fairly active lifestyle prior
to her injury, and lived at home with family
members.
Her external fixator was removed after twelve
weeks and a total contact cast was applied. At that
time, radiographs revealed disuse osteopenia,
fracture healing and good alignment. At two years
follow up, she had a clinically stable ankle joint and
a propulsive, plantigrade foot. (Figs. 5 and 6)
9
The Journal of Diabetic Foot Complications
D
Open access publishing
iscussion
Isolated non-displaced fractures of the
medial malleolus are generally considered
stable with an anatomic mortise on radiographs.10
Although there have been studies suggesting
successful outcomes with non-operative treatment1,
10
, there remains an uncertainty associated with the
soft-tissue injury that may lead to a late-subluxation
of the ankle.6 A recent study found that isolated
non-displaced medial malleolus fractures when
treated non-operatively had high rates of union and
functionality at three years of follow-up.10
However, the study did not specifically discuss its
patient population’s medical history, and whether
this may play a role in outcomes. We believe in our
case that the patient’s history of diabetes with
neuropathy led to her complicated treatment course.
Figure 4 Post-operative radiograph reveals her ankle is
reduced into anatomic position.
A
According to Wukich and Kline14, isolated stable
non-displaced fractures of the medial malleolus are
generally treated successfully with non-operative
treatment, however frequent follow-up and
examination are mandatory for a successful
outcome in diabetic patients. It has been often
reported in the literature of the higher rates of
complications for ankle fractures for patients with
diabetes.4,11,12 These complication rates are even
more impressive in patients who also have
peripheral vascular disease, neuropathy, and poor
compliance with their diabetes treatment
regimen.8,14
B
The medial malleolus and deltoid ligament complex
have been shown to be important in maintaining
stability in the ankle.5,10 Significant changes in
ankle contact characteristics due to soft-tissue injury
may occur prior to radiographic evidence for
significant damage.5 Injury to the deltoid ligament
complex can lead to ankle instability, resulting in
complications such as non-union, mal-union,
arthritis, and ankle dislocation.5 However, a key
criterion to direct appropriate treatment to the area
is the physical finding of pain. In patients with
diabetic sensory neuropathy, the absence of pain
may allow subtle ankle instability to go undetected.
Figure 5A and B Patient at two-year follow-up reveals
a stable and anatomic ankle joint.
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The Journal of Diabetic Foot Complications
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Shibata, et al.,13 described a prodromal,
inflammatory stage (“Stage 0 Charcot”) where
distinct radiographic changes are absent, but the
patient presents with localized increased skin
temperature and erythema as the primary
symptoms.
If left unrecognized and untreated,
Charcot arthropathy can progress to a destructive
stage (“Stage 1 Charcot”) as evidenced by
radiographic changes of bone and joint
architecture7. The resolution of the Charcot process
eventually leads to decreasing warmth, redness, and
swelling, and radiographic coalescence of fracture
fragments (“Stage 2 Charcot”). The last phase
(“Stage 3 Charcot”) is characterized as the
remodeling and consolidation of fracture fragments
leading to osseous deformity. This chronic phase of
Charcot arthropathy is without the warmth, redness,
and edema as in previously stages, but the final
consolidation can result in either a stable or unstable
deformity.15 Ideally, Charcot arthropathy should be
diagnosed and treated as early as possible to avoid
these devastating consequences.
A
B
Our patient with diabetic sensory neuropathy
presented with an acute non-displaced fracture
initially to the emergency department. According to
recent literature15, this can be characterized as Stage
0 Charcot, the prodromal presentation of Charcot
Although she was treated
arthropathy.
appropriately, the significance of her diagnosis may
have not been fully understood by the patient. The
lack of sensory awareness and pain feedback
removes a vital barrier of protection, and may have
even masked the severity of her injury as evidenced
by radiograph. It is well supported in the literature
that neuropathy in patients with diabetes is the
primary risk factor for developing ulcerations.2, 9
Figure 6A and B Clinical photos of patient’s ankle after
two years of follow-up demonstrating a plantigrade foot.
The lateral abrasions are unrelated to the original injury.
In our case, the patient’s treatment course was
compromised by the development of acute Charcot
arthropathy, ulceration, and cellulitis. Although
immobilized and instructed to remain non-weight
bearing during her initial visit, the patient had
rapidly developed acute Charcot arthropathy within
three weeks of her reported injury. The rapid
progression of the joint destruction, even with
immediate immobilization and non-weight bearing
status, is not uncommon for diabetic patients with
neuropathy.15
Patients with diabetes have an increased rate of
complications associated with ankle fractures
whether treated non-operatively or operatively.14
Although an isolated non-displaced medial
malleolus fracture is typically benign in clinical
behavior, clinicians treating diabetic patients with
neuropathy may need to take extra precaution in
these seemingly minor injuries.
The initial presentation of Charcot arthropathy of
the foot and ankle is commonly described as
painless, warm, edematous and erythematous.15
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The Journal of Diabetic Foot Complications
Open access publishing
As outlined by Wukich and Kline14, clinicians
dealing with patients with diabetes should adjust
their standard protocol for treatment of ankle
fractures. This includes prolonging their period of
non-weight bearing, followed by a prolonged period
of protected weight bearing. The amount of followup should also be “doubled” for all diabetic ankle
fractures because vigilance is needed in preventing
complications.
R
11. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman
MB, Estin M, Saltzman CL. Ankle fractures in patients with
diabetes mellitus. J Bone Joint Surg Br. 2005;87(4):489-495.
12. McCormack RG, Leith JM. Ankle fractures in diabetics.
Complications of surgical management. J Bone Joint Surg Br.
1998;80(4):689-692.
13. Shibata T, Tada K, Hashizume C. The results of
arthrodesis of the ankle for leprotic neuroarthropathy. J Bone
Joint Surg Am. 1990;72(5):749-756.
14. Wukich DK, Kline AJ. The management of ankle
fractures in patients with diabetes. J Bone Joint Surg Am.
2008;90(7):1570-1578.
15. Wukich DK, Sung W. Charcot arthropathy of the foot and
ankle: modern concepts and management review. J Diabetes
Complications. 2008.
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