Life Impact of Ankle Fractures

Qualitative Analysis of Patient and Clinician Experiences

Steven M McPhail; Joel Dunstan; Julie Canning; Terry P Haines


BMC Musculoskelet Disord. 2012;13(224) 

In This Article


Traumatic musculoskeletal injuries are a common problem that may result in short or long term pain and disability.[1–5] Fractures around the ankle are one of the more commonly occurring forms of trauma managed by orthopaedic teams worldwide with Australasian data citing an incidence of 43.5 fractures per 100,000 persons per year.[6–8] Despite their high incidence, ankle fractures may be considered by some to be a 'lesser' injury in comparison to other fractures (such as multiple trauma, hip fractures or fractures of the axial skeleton) and have attracted less empirical research in comparison to other common fracture types.[9–14] This potential consideration of ankle fractures as a lesser injury may be due to a perception that ankle fractures are localised in nature and have a high success rate of fracture reduction and union with established treatment protocols.[9,15] However, any perception that ankle fractures have a low rate of sub-optimal outcome and negligible negative long term consequence are not founded in empirical data. Prior empirical research has indicated the impact of ankle fractures may not be restricted to pain and disability caused at the time of the incident but continue for an extended duration.[9,15]

Long term effects of ankle fractures have been reported to include physical, psychological, and social consequences.[9] It has been reported that physical impairments following ankle fractures may include pain, functional impairment and the development of post-trauma arthritis.[16] Negative psychological consequences following ankle fractures have been reported to include fatigue, depression, anxiety and sleep disturbances.[9] Negative social consequences have included difficulty returning to work and dependence on disability benefits.[9] These types of negative consequences are comparable to those that have been reported among other severe fracture types.[13,17–20]

There is some controversy as to the proportion of patients who recover well following ankle fractures.[21] Some previous studies have identified that 52% to 87% of patients have good to excellent clinical outcomes after an ankle fracture.[7,22–25] In contrast, a number of follow-up studies looking at patient outcomes between 14 months and 6 years following fracture have found that few patients reported a full recovery in most areas.[8,9,26] Specifically, 52% of patients had psychological complaints due to the initial injury,[9] and 52% had difficulties with sport activities.[8] Nilsson, Nyberg et al.[26] found that 51% self-report poor function with complaints of ongoing stiffness and swelling, pain with walking, and an impaired ability to climb stairs. A recent systematic review of long term outcomes from 1822 ankle fractures across 18 studies (4 to 14 years follow up) reported that approximately one in five did not result in a good or excellent outcome.[15] In these investigations, success was classified according to performance against a set of researcher-selected subjective symptoms and objective findings.[15] Additionally, measurement methodologies were frequently not described in detail or had not been tested for reliability and validity.[15] Insufficient or sub-optimal rehabilitation has been cited as a potential cause of long-term disability in this population.[26] However, a Cochrane systematic review of ankle fracture rehabilitation in adults highlighted that limited evidence is available at present to inform specific rehabilitation protocols for clinical practice.[27]

One limiting factor when planning and conducting research among people with ankle fractures is the absence of a suitable ankle fracture specific patient-reported outcome measure. The inclusion of patient-reported outcomes as primary measures has become increasingly common across a wide range of clinical and research settings.[28–33] Common patient-reported outcomes that are frequently used among people with musculoskeletal conditions include measures of pain,[34–36] physical function activity limitations[37–39] and health-related quality of life.[40–45] The use of patient-reported outcomes permit clinicians and health researchers to evaluate the effectiveness of an intervention based on the lived experience of the person with the condition under consideration.[35,46–48]

Condition-specific patient-reported outcome measures should reflect those areas of life that are meaningfully influenced by the condition under consideration from the perspective of the patient.[49,50] The areas of life influenced by the condition may extend beyond physical functioning activity limitations.[9] This is in contrast to clinically derived measures that may focus on constructs that health professionals consider to be important (such as changes detected in x-ray images, joint range of motion or clinical performance tests).[51–53] A condition-specific patient-reported outcome measure for use among ankle fracture patients during their rehabilitation should capture the effects of rehabilitation which patients (rather than health professionals) consider most important.[49] These effects must also be evaluated in a way that is valid, reliable and responsive to change over the entire rehabilitation period.[54,55]

Investigations of ankle fracture rehabilitation included in a Cochrane systematic review of ankle fracture rehabilitation focused on clinical outcomes; including ankle range of motion and performance tests.[27,56] Some investigations used patient-reported outcomes to assess health professional defined physical activity limitations.[57–62] The most frequently used patient-reported outcome for this purpose was the Olerud Molander Ankle Scale.[27,63] This scale was reported by Olerud and Molander in 1984 to improve the way ankle symptoms were evaluated.[63] The scale includes nine parameters focusing on physical symptoms and physical activities (walking, stiffness, swelling, stair-climbing, running, jumping, squatting, physical supports, and work capacity).[63] The scale includes two to five multiple choice response options for each parameter which the authors of the scale assigned a value of 0, 5, 10, 15, 20 or 25 (maximum total score is 100).[63] While this scale is practical and represented advancement beyond describing ankle symptoms into overall subjective categories such as a 'good' or 'poor' outcome, the scale has been criticised for lacking a methodologically robust foundation with content and scores based on expert opinion alone.[47] There is also a marked lack of empirical evidence reporting favourable psychometric and clinimetric properties for this scale.[47,55,63,64]

Absence of a robust content foundation or empirical evidence indicating favourable clinimetric properties is also a shortcoming of other patient-reported outcomes for the foot and ankle.[47,57–59,62,64] Other patient-reported measures identified in the Cochrane review of ankle rehabilitation included the Clinical Demerit Points (based on the Weber Protocol),[62] Lower Extremity Functional Scale (LEFS),[60,65] Inflammatory Score,[61] Maryland Foot Score,[59] a visual analogue scale[58] and a grading scale by Mazure in 1979.[57] These measures lack a methodologically robust foundation for evaluating life impacts experienced by ankle fracture patients during their rehabilitation.[47,49] Their content and scoring are commonly based on expert opinion alone and tend to focus on physical symptoms or activity performance. With the exception of the LEFS, these measures also lack empirical support for key elements of validity, reliability and responsiveness.[47,57–59,62,64]

The LEFS has demonstrated favourable clinimetric properties in non-ankle fracture populations,[65–67] and during the acute phase of ankle fracture recovery.[68] However, the ceiling effect observed after the acute phase of ankle fracture rehabilitation is detrimental to its use as a primary outcome measure throughout the entirety of the rehabilitation process.[68] Additionally, the content (and subsequent scoring) of the LEFS focuses heavily on elements of performance related to physical tasks (including walking, squatting, running, standing, stairs, hopping).[65] This is not necessarily a weakness for an instrument intended to assess patients' ratings of their lower extremity physical function. The LEFS has a solid foundation of empirical data supporting its use for this purpose.[65,67,69] However, the LEFS was not developed with an empirical foundation for use as an ankle fracture condition-specific patient-reported outcome measure intended to evaluate the life impacts (including non-physical impacts) that are most meaningful to patients recovering from an ankle fracture.[9]

In summary, a range of patient-reported outcomes have been used among people with ankle fractures. These measures frequently have some methodological foundation in previous examinations of particular aspects of validity and reliability. However, ideally patient-reported outcomes should have foundation in patient-reported impacts, in addition to performing well in studies reporting aspects of validity, reliability and responsiveness to change. Including the patient's perspectives when evaluating ankle fracture interventions may be problematic in the absence of a condition-specific patient-reported outcome measure empirically derived from lived patient experiences.[49] Existing foot and ankle outcomes were designed to evaluate physical symptoms and activity performance across a range of lower limb conditions.[47,63–65] These measures are unlikely to capture the most salient physical and non-physical impacts experienced by people recovering from ankle fractures.[9]

This study aimed to investigate the nature of life impacts following ankle fractures with the intention of describing a thematic conceptual framework based on these lived experiences of people who have suffered ankle fractures. The investigators considered the description of this thematic framework as a critical first step in the development of an ankle fracture specific, patient-reported outcome measure suitable for evaluating the impact of an ankle fracture on patients' lives. The development of such a measure into a questionnaire format would likely permit efficient and effective assessment of the impact of ankle fractures on patients' health-related quality of life (not just their physical activity limitations). A questionnaire for this purpose would have application in both clinical and research settings. This measure could have potential use at a single assessment or as a repeated measure to evaluate recovery (or decline) longitudinally. This would allow use in both observational and intervention studies; including clinical trials evaluating the effectiveness of ankle fracture rehabilitation protocols. Therefore, the purpose of this study was to not only investigate the nature of life impacts in the acute post-injury phase of recovery following ankle fractures, but to include life impacts across the recovery continuum and returning to work and usual daily living.