Ankle fractures. Outcome and rehabilitation. A physiotherapeutic perspective

Abstract: The overall aim of this work was to evaluate symptoms, subjectively scored function and physical outcome in patients with surgically treated ankle fractures. Another aim was also to evaluate the effects of a standardised but individually suited supervised training program. In all, 209 patients with surgically treated ankle fractures were included in three different samples: 54 individuals aged 18-64 years (Paper I, II and III), 50 individuals aged 65 years or older (Paper IV) and 105 patients 18-64 years (Paper V). Fifty-four uninjured persons served as a control group (Paper III). Subjective outcome was evaluated by the Olerud-Molander Ankle Scale (OMAS), the Linear Analogue Scale, Self-rated ankle function using an ordinal scale and SF-36. Physical outcome was evaluated by ankle range of motion, muscle strength in the plantar flexors and dorsiflexors, balance tests by one-leg stance on the floor and by stabilometry. Furthermore timed walking tests in a stair-case and on plain ground was evaluated. Radiological outcome was performed pre-surgery, immediately post-surgery and 12 months after surgery. Symptoms like pain, stiffness, swelling, functional ankle instability and problems when stair-walking were frequently reported from subjects in working ages one year after injury and almost fifty percent had not returned to their pre-injury physical activity level (Paper I). Subjects 40 years of age or older reported lower subjective function as measured by the OMAS compared to those under the age of 40 (Paper II). Ankle range of motion, muscle strength in the plantar flexors and dorsiflexors and standing balance capacity were decreased in the injured leg compared to the uninjured. Results from the physical tests were reflected in subjective outcome as decreased physical outcome was associated with lower subjective outcome (Paper I). At the 14-month follow-up all fractures were healed, in 40 out of 51 cases with no displacement and in eleven cases with slight displacement. Fractures with bimalleolar internal fixation showed more frequently residual displacement than those with unimalleolar fixation. Ankle osteoarthritis had developed in ten out of 51 patients, only in subjects over 40 years of age, more often in women and more often in fractures requiring bimalleolar internal fixation (Paper II). Only 40 of the 54 patients managed to complete the 25 second single-limb stance test on the force-platform whereas all controls managed. Poorer results were found in the patients’ injured leg compared to the uninjured whereas no differences were found between patients injured leg and the side-matched leg of the controls. Age over 45 years and decreased strength in the ankle plantar flexors and dorsiflexors provided a higher risk not managing the stabilometric test (Paper III). In patients 65 years or older subjectively scored function improved between six- and twelve month follow-up but still one year after injury symptoms, functional limitations and reduced physical activity were frequently reported. Health related quality of life (SF-36) was reduced in three subscales at six-month in women compared to the age and gender matched normative data of the Swedish population. At twelve month the differences were eliminated. (Paper IV). Only subjects under the age of 40 had benefits from a twelve week standardised but individually suited supervised training program starting within one week after plaster removal. Both subjectively scored function, health-related quality of life and results from a number of physical measurements were superior in the training group compared to the usual care group. At twelve months most differences had levelled out except for subjectively scored function (OMAS), muscle strength in the plantar flexors, walking speed and dynamic balance (Paper V). In conclusion, from the findings in this thesis functional limitations can be expected at least one year after a surgically treated ankle fracture and more frequent in middle-aged and older persons. The standardised but individually suited supervised training model as designed in this thesis may be useful in subjects under the age of 40. Future studies should focus on a deeper understanding of the problems in the middle-aged and elderly.