Special thanks to star physical therapist Brace Hayden, DPT, CSCS of Alpine Physical Therapy for providing this write up on a recent article from The Journal of Bone and Joint Surgery.
It is widely accepted in trauma care that a fractured ankle will usually require surgical stabilization, as bearing weight and walking on the broken bone(s) is imperative to functional progress. Controlling the swelling or edema that comes secondary to the injury is an important consideration in expediting the surgical intervention and subsequent rehabilitation. Excessive edema can complicate the surgery and healing, as well as increase the risk of wound complications and infection following the surgery.
Manuela Rohner-Spengler, a clinical Physical Therapist and a team of MD/PhDs from the Departments of Rheumatology and Physiotherapy and Trauma Surgery at the Lucerne Cantonal Hospital in Switzerland took interest the optimal pre-operative swelling management techniques to yield the best post-operative outcomes. In an age of improving medical care with more sophisticated equipment, Ms. Rohner-Spengler and her team wanted to know how effective are new dynamic compression therapies like intermittent impulse compression devices, at reducing ankle edema compared to the standard treatment of elevation and ice?
This study followed rigorous design methods using randomized, controlled, single-blinded clinical trials with repeated-measures on each subject. The 58 subjects all had a similar traumatic injury of fracturing one of their ankles. They were randomly assigned into one of three groups; the standard cold pack and elevation (control) group, the compression bandage group (aka. Ace wrapping), or the impulse compression (a pneumatic compression sock) group. The resulting measures from the various treatment groups were analyzed with intention-to-treat principles, meaning all resulting measures were based on the initial treatment grouping assignment and not on the treatments the subjects eventually received.
Each subject had their ankle girth measured with a flexible tape measure using the figure-of-eight method for 5 consecutive days before and after the surgery, then again at 6 weeks post-op. Other measurements tracked through the study were degrees of ankle mobility, pain levels, number of days in hospital, Physical Therapy treatment sessions, amounts of medication required, wound-healing measures and functional outcome data using the Foot and Ankle Ability Measure.
This study found significant differences in edema reduction both pre-operatively and post-operatively between the compression bandage group and the ice and elevate (control) group. The pneumatic compression sock group did not make significant reductions in ankle edema. For example, after two days of pre-operative intervention, the median edema reduction was -23%, -5%, and 0% for the compression bandage, control group and pneumatic compression group respectively. Another interesting difference noted was improved ankle range of motion following the surgery in the control group over the compression bandage and pneumatic ‘impulse’ squeezer sock.
Shortcomings of this study were the impulse compression device had to be used as a ‘stand-alone treatment’ and thus other secondary typical pre or post-operative edema reduction measures like elevation, cold pack application and compression wraps were not used. The study design also could only use single-blind methodology, which reduces its strength and validity, but it is nearly impossible to blind the subject pool as to what type of treatment they were receiving. Do I have a cold pack on my ankle or is that one of those nifty pneumatic ‘impulse’ squeezer socks?
The take-away findings for patients that have an acute ankle trauma are multilayer compression wrapping can be very effective at reducing swelling before and after surgery. Using combinations of cold packs, elevation and compression therapy can thus be inferred to be helpful for reducing pain, improving ankle range of motion and mitigating edema. Implementing compression wraps with stabilization splints/boots in the emergency room, as well as post-operatively could also lead to a more efficient, less painful healing time.
Manuela Rohner-Spengler, MPTSc, et al. Effective Treatment of Posttraumatic and Postoperative Edema in Patients with Ankle and Hindfoot Fractures. A Randomized Controlled Trial Comparing Multilayer Compression Therapy and Intermittent Impulse Compression with the Standard Treatment with Ice. In The Journal of Bone and Joint Surgery. Vol 96-A, Number 15, August 6, 2014.
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