Too many choices: Ankle sprain treatment - ace wrap, brace, or boot?

Clinical Scenario:
A 22 year old was running in the park when she accidentally rolls her ankle on the uneven ground.  There is significant swelling over the lateral malleolus that is tender to palpation.  She is unable to bear weight on her ankle so you obtain x-rays, which are normal.  As you are about to send her home, you debate what is the best treatment for her ankle.

Clinical Question:
In a severe ankle sprain, what is the preferred treatment – ace wrap, aircast brace, or air walker boot?

Literature Review:
Grade I injury is a mild stretching of the ligament without joint instability, Grade II injury is a partial rupture of the ligament with mild instability, Grade III is a complete rupture of the ligament with joint instability.   Generally grade II or III are considered severe sprains.

A study released in the Lancet in 2009 compared 584 participants with severe sprains who received a below-knee cast for 10 days, ace wrap, aircast brace, or an air walker boot.  The patients were followed up at 3 months and assessed for quality of ankle function, pain, symptoms, and activity.  The superior method of treatment was the 10 day below-knee cast (when compared to the ace wrap) for overall quality of ankle function (mean difference 9%; 95% CI 2.4-15.0).  The aircast brace was also found to improve quality of ankle function compared to ace wrap and air walker boot, but was not superior with regard to pain, symptom, or activity.  The air walker boot was not superior to the ace wrap.  Another study from 2005 compared ace wraps to the aircast brace for lateral ankle sprains and also found that the aircast ankle brace was superior to an ace wrap at 10 days and one month. In a systematic review published in Sports Med in 2011, they too concluded the superiority of an ankle brace over an ace wrap with regard to functional outcome.

The British Medical Bulletin in a systematic review concluded that for mild to moderate ankle sprains, functional treatment options (ace wrap, aircast brace) where found to be statistically better than immobilization.  For severe ankle sprains, a short period of immobilization in a below-knee cast resulted in a quicker recovery than other functional treatments

Take home points:
-The most practical approach is to offer an aircast brace, which has been shown to offer better functional outcome compared to ace wrap and air walker boot.
-In severe ankle sprains, short below-knee cast immobilization resulted in the best functional outcome

1. Boyce SH, Quigley MA, Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med. 2005 Feb;39(2):91-6.
2. Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW; Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: a pragmatic, multicentre, randomised controlled trial. Lancet. 2009 Feb 14;373(9663):575-81.
3. Kemler E, van de Port I, Backx F, van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011 Mar 1;41(3):185-97.
4. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97:105-35.

Images from: www.1staidsupplies.com, www.betterbraces.com, orthotape.com.

Submitted by Lydia Luangruangrong, PGY-3.
Edited by  Steven Hung (@DocHungER), PGY-2
Faculty reviewed by Chris Brooks

...And We All Fall Down... Eventually : Nonpharmacologic pain management for hip fractures in the elderly?

Your patient is an elderly male with history of dementia and multiple medical comorbidities who is sent to the emergency department after a fall from standing. He complains of left hip pain and his X-rays demonstrate a comminuted intertrochanteric left hip fracture. Since the elderly and demented constitute an at-risk population for inadequate analgesia as well as increased risk of fall, respiratory depression and delirium from polypharmacy, you wonder what nonpharmacologic pain control interventions may supplement your pain control management for this patient?

Clinical question: 

Are nonpharmacologic pain control interventions effective in treating pain associated with hip fracture? Do nonpharmacologic pain control interventions reduce the need for opiates in patients with hip fracture?

The Literature

Several studies have examined the efficacy of skin traction (foam boot connected to weight via pulley) versus position of comfort (pillow support) for pain relief in patients with various hip fractures. In two randomized studies, skin traction showed no benefit over pillow support:
The first study, published in 2001, was a randomized study enrolling 100 participants. They compared skin traction with a 5lb weight versus pillow support. The authors found that patients who were treated with pillow support required less pain medication and reported statistically significantly lower pain scores prior to surgery (after overnight stay awaiting operative intervention) than their traction treated counterparts (p 0.04). They had an average reduction of pain score of 2.82 points versus a reduction of 1.76 points. The average age of patients in the study was 78 and nearly half had intertrochanteric hip fractures (other half were femoral neck fractures). The study was limited in that they excluded demented patients in their study as they were felt unable to demonstrate adequate understanding of the pain scale and reliably report pain scores.
The second study, released in 2010, included 108 patients randomized to either weighted traction, unweighted traction apparatus or pillow support. Similarly, they observed no difference in pain control between pillow and weighted traction. However, unweighted traction had a statistically significant improvement in pain control compared to the other two. They attributed this to a placebo effect as it provided no actual support of the fracture fragments and did not restrict movement.
Neither study reported negative outcomes associated with pillow treatment, however both observed minor negative outcomes with skin traction either weighted or unweighted. These included blistering, pressure sores and neurapraxia.

Take home: 

- At least two studies demonstrate no improvement in pain control by employing skin traction over pillow support. 
- Moreover, while the pillow group had no reported negative outcomes related to treatment, the skin traction groups in both studies reported wounds, blistering, nerve compression, and pain with application of the treatment. 
- In this population with advanced age, comorbid illness, and potentially limited ability to sense or communicate discomfort with a boot, these minor problems could develop important long term sequelae.
- My treatment plan for the next elderly hip fracture: Pillow support + adequate pharmacologic analgesia + consideration for local nerve blocks. 

1) Rosen, JE et al, “Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study,” 2001. Journal of Orthopedic Trauma. Vol. 15(2) 81-85.
2) Sayqi, B et al, “Skin traction and placebo effect in the preoperative pain control in patients with collum and intertrochanteric femur fractures.” 2010 Bulletin of the NYU Hospital for Joint Diseases. Vol. 68(1) 15 - 17.

Contributed by Sara Manning, PGY-3