The effects of shared decision making in the conservative management of stable ankle fractures

Introduction: The majority of ankle fractures seen in clinic are stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable ankle fractures are advised that they need a cast. In this study we counseled patients regarding the different options for conservative management of their stable ankle fracture. We then encouraged them to make an informed decision on which method of treatment they would like to pursue.

Materials and methods: We analyzed eight years of a single consultant's fracture clinic. 163 patients were offered a choice of: a weight bearing below knee cast; a functional ankle brace; or a regime of rest, ice, compression bandage and elevation ("RICE" regime). All patients were advised to mobilize on the injured ankle as their pain allowed.

Results: 163 patients were suitable for all 3 treatment options. 82% (133/163) chose an ankle brace, 15% (25/163) opted for a RICE regime and 3% (5/163) chose a below knee cast. Of these only one returned to clinic complaining of increased pain, however after further discussion the patient opted to continue with his RICE regime as planned.

Discussion: A conservative approach to these injuries is now common practice; however there is a wide variation in what type of conservative management is given. Recent studies suggest orthopedic surgeons are still treating the majority of these injuries with a weight-bearing cast despite risks of stiffness, skin damage and thromboembolism. This study showed when the patient is given opportunity to make an informed choice the vast majority opt not to have a cast. The study suggests management of these injuries should be decided via a two-way conversation between patient and practitioner.

Conclusions: Using a shared decision making approach to these injuries is a useful method of providing patients with the most suitable treatment for their personal treatment goals.