A Useful New Definition of “Unstable” for Ankle Fractures

A great way to avoid overtreatment of a common fracture.

What’s the Claim?

Patients with a Weber B ankle fracture (which may be an SER-II or an SER-IV fracture without bony involvement) may be stable or unstable. A well-designed observational study in JBJS compared patients with stable fractures (no medial widening on gravity stress radiographs or weightbearing radiographs a week after injury) to those demonstrating medial widening on gravity stress radiographs whose weightbearing x-rays showed no instability. Those with instability on weightbearing x-rays were treated surgically.

It found that so-called “unstable”" fractures (as defined by gravity stress radiographs, which generally is the accepted approach these days, as long as the weightbearing x-ray showed no instability) did no worse than stable fractures in terms of outcomes scores and imaging 2 years later.

This is a big finding — 41% of the fractures in the study had positive gravity stress radiographs. Many surgeons would’ve offered all of those patients ORIF. This study suggests that doing so is likely to be too much treatment, since they did just as well without surgery.

How’s It Stack Up?