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


Thirteen patients and six health professionals were invited to participate in the investigation after responding to the study advertisement (and being deemed appropriate in meeting one of the required purposive sampling strata). However, one patient was not able to find a suitable time to schedule an interview, so declined participation. Twelve patient interviews and six health professional interviews were undertaken and included in analysis. Patient demographic and clinical information, including a brief summary of patients' descriptions of their ankle fractures are presented in Table 1. The sample included diverse causes of ankle fracture and patient ages. There was equal gender representation. Seven patients reported receiving surgical stabilisation (each of these descriptions consistent with open reduction, internal fixation). Health professionals included an Orthopaedic surgeon (1), physiotherapists (3), a podiatrist (1) and an occupational therapist (1). Experience of health professionals ranged from 1 year to 16 years working with people with ankle fractures.

Data saturation occurred after ten patient interviews; with the final two patient interviews not contributing any further themes or categories. Data saturation being reached after only ten interviews may have occurred due to inclusion of patients who had experienced diverse and severe impacts following their ankle fracture. The rich and somewhat exhaustive data contributed by these patients covered a large proportion of categories included in the final thematic framework. The final framework is presented in Table 3. The eight emerging themes included Physical, Psychological, Daily Living, Social, Occupational and Domestic, Financial, Aesthetic and Medication Taking. The six health professional interviews were coded to this framework (Table 3) without addition of any further themes or categories. Phrases from the health professional participants were most frequently aligned under categories in the Physical or Occupational theme; few were aligned under the Psychological, Aesthetic or Social themes. Example quotes for each of the eight themes are also presented in Table 4. These quotes were selected being as representative of the overarching theme and diversity of life impacts across the patient sample.

Theme 1: Physical

A broad range of physical impacts were described by both patients and health professionals. These impacts included mechanical elements (swelling, reduced muscle strength, decreased range of motion) and associated afferent impacts (pain, discomfort, altered sensation etc.). Responses that described difficulty with walking without reference to any specific occupational or daily living impact were also grouped into this theme. For example, one participant noted "I am limited on how far (and) fast… I can walk" (p6). Impacts in this theme were not limited to the immediate post-fracture period: "it was (many) months before I got the movement back" (p10).

Pain was the primary emerging category reported by patients in this theme. Patient participants reported "pain was the number one problem" (p1). Immediately after the fracture and following the removal of the plaster, participants recalled substantial pain in their ankle. The present level of pain amongst the patient participants (of varying duration since injury) was heterogeneous with some reporting constant or daily pain; others described how the pain "just got better over time" (p5). Swelling was also identified as a major concern for patients, particularly immediately following plaster removal.

Health professional responses were focused within the physical impacts theme more than any other. Health professionals identified pain as a primary impact of the ankle fracture that may not resolve after the initial post-fracture period. One health professional stated most of the patients are usually "feeling quite a bit of pain" (hp1) during the early post-fracture period another stated "…pain is still a problem months after the cast (is) off for some (patients)" (hp4). Health professionals were generally more articulate with their responses in this theme than patients. One health professional noted "…restricted dorsi flexion is usually a problem" (hp4) not only identifying restricted range of movement, but also commenting on a specific direction of movement commonly affected. Health professionals reported that swelling will be present, can be persistent and often causes discomfort.

Theme 2: Psychological

Participants reported a range of psychological and emotional impacts attributed to their ankle fracture that were grouped into this theme. These included depression, anxiety, frustration and tiredness or fatigue. Responses grouped into this theme were often described in relation to another impact. For example "I was just so frustrated (that) it ached no matter what I did,"(p10) and "…ongoing pain just wore me out… I felt tired all the time" (p8).

The severity of psychological impacts reported by patients was not consistent across respondents. Responses from patients about feelings of depression ranged from being "…at an all time low in my life…" (p10) to "…it is a bit depressing" (p2). Most participants stated that negative feelings resolved as they were able to return to activities undertaken prior to their ankle fracture. However, some participants reported ongoing unresolved anxiety or depression months after plaster removal. A participant who had experienced a difficult recovery after fracturing his ankle 18 months earlier stated he tended to "feel quite depressed and down a lot, and dwell on what happened and keep replaying things in (his) mind" (p10).

Health professionals infrequently described impacts that were aligned in this theme. Despite fewer responses in this theme, the impacts described were consistent with those described by patients. One health professional noted "…some get a bit depressed about their situation" (hp5). Another recalled working with patients who had become anxious about the risk of re-fracturing the ankle despite x-ray evidence of sound healing and reassurance from the health professional that fracture recurrence was not likely.

Theme 3. Daily Living

The primary emerging category in the daily living theme was the impact on participation in preferred recreation or leisure activities. Participants reported many of the recreational and leisure activities they had participated in prior to the ankle fracture were not possible or had to be modified following the ankle fracture. Both patients and health professionals reported substantial impacts on health and fitness activities. Impacts on personal care tasks were generally described in the context of the early post fracture period, as were difficulties with sleeping.

Many patient participants stated they could still do aspects of their previous activities after sustaining the ankle fracture, but needed to alter these as a result of the fracture. For example one participant was still able to go swimming, but was not able to use a flipper since the fracture. Another participant stated "I modified the activities I do so it's less demanding on the ankle but still enjoyable' (p2). Some had stopped participating in recreation or fitness related activities altogether due to ankle fracture reporting they felt they "couldn't do anything" (p12). Patient participants reported their ability to go walking or running was decreased, with one participant stating he was still unable to return to jogging almost a year post ankle fracture. Another stated "I can now only go walking (for) about one and half kilometres… I used to walk 5km (regularly)" (p7).

Health professionals described a range of impacts in this theme that were congruent with responses from patients. They similarly reported substantial impacts on health and fitness activities as well as a range of impacts grouped into the other three categories in this theme (Table 3). However, at least one health professional felt that some patients continued to avoid physical activity long after there was any anatomical indication to do so. They reported this often occurred despite reassurance that it was not only safe, but beneficial to return to living a healthy active lifestyle. The health professionals also commented that many patients have unrealistic expectations about how quickly their ankle will heal and they will be able to return to their usual activities. With one stating "patients often think their ankle will get better quicker than it does" (hp2).

Theme 4: Social

Impacts that were grouped within the social theme were diverse. In summary, they included the ability to undertake informal social activities with friends or family as well as reduced participation in formal social gatherings. Reports of the impact of their ankle fracture on ability to socialize differed across participants. Some stated that they had felt a decreased ability to be able to socialize with friends whereas as one patient stated they could still "hang out with people" (p3) and they actually spent more time with their friends than prior to their ankle fracture.

Some patients reported that they could not participate in many social activities so there was no point attending social gatherings. One participant reported staying home so she could keep her foot elevated instead of seeing friends. A number of participants felt they were a burden to friends and family. One patient stated he "felt like (he) let (his) wife down" (p2) and that it had negatively impacted their relationship. Participants reported they did not want to be "a drag or pain" (p1) to their friends or family.

Health professionals infrequently reported responses in this theme. They did however note the increased burden for family members who may be required to assist older adults who have fractured their ankle and have difficulty with certain tasks. One health professional also noted that some patients resist becoming dependent on others in their household, even for a short period, while others seem more than happy for this to occur.

Theme 5: Occupational or Domestic

Both patients and health professionals reported impacts on a range of tasks included in this theme. These tasks included those involved with maintaining a household, paid employment or volunteer work. Some impacts reported in this theme were short lived and resolved after the initial post-fracture recovery and return to gait without the use of walking aids. Other impacts were long lasting and resulted in a career change for some.

The most frequent impact reported by patients was the need for light or modified duties at work and a reduction in home duties. Light or modified tasks at work had a major impact on most participants. Many reported that they "…could not work fulltime" (p1) and were restricted in their ability to work in the immediate post-fracture period. Many participants stated that everyday domestic activities were very difficult to do and that many "didn't do much housework" (p9). Some participants who had returned to normal gait reported they were currently experiencing no limitation with occupational and domestic tasks stating their ankle is "no problem" (p5) and "has no effect at all" (p9) on current occupational and domestic tasks. In contrast, another participant stated "I did not work for eleven and a half months… I ceased (my occupation) at that time" (p10). That participant had subsequently changed occupations to a less physically demanding role.

The severity of impact on work activities reported by health professionals varied widely. Health professionals reported that some patients had changed occupations after the ankle fracture due to the specific physical demands of their role. One health professional noted this seemed to happen more often when the patient worked in a "manual labour intensive" (hp6) role in the immediate pre-fracture period. Health professionals reported that impacts on occupational and domestic roles were usually short-lived and most people returned to pre-fracture roles within the first few months following the fracture.

Theme 6: Financial Impact

Responses in this theme included the financial impacts that were directly attributed to the ankle fracture. Responses focused on reduced income due to time off work, reduced work hours or an altered work role. An associated impact was the use of savings to compensate for reduced income or greater expenses (including expenditure on healthcare costs).

Patients reported financial impacts of mixed severity. Participants frequently reported reduced income as the primary financial impact. Many participants stated they were "out of work so it affected money" (p11) or suffered "loss of income as (I was) unable to work at full capacity for some months" (p2). However, patients also reported financial impacts that included reliance on savings and being forced to reduce their discretionary spending to compensate for the reduced income.

Health professionals frequently described impacts on paid employment activities. However, they did not extend this to include a description of personal financial implications.

Theme 7: Aesthetic Impact

Responses grouped into the aesthetic theme included those that related to physical appearance, rather than function or other health attributes. Two distinct categories emerged in this theme; weight gain and having to wear non preferred footwear. Some responses about weight gain were discussed by patients in the context of health and fitness (and grouped into the health and fitness category), rather than under the Aesthetic Impact theme.

Patients reported impacts from footwear limitations and concerns with their appearance following weight gain they had attributed to the ankle fracture. Limitations with footwear were identified by almost all the female patient participants, and this was usually connected to the inability to wear high heels. One participant stated "I wanted to wear high heel shoes to my daughters wedding… so I got quite upset when… (I) couldn't wear high heels to (my) daughter's wedding" (p1). Footwear comments were not limited to female participants or to high heels. One male participant reported "I couldn't just wear flip flops (uncovered recreational footwear)." A number of patient participants reported impacts on their appearance or clothing choices due weight gain since fracturing their ankle. One participant reported "I was (a little) bit concerned about how I looked…"(p6) after she "…had put weight on" (p6).

Health professionals described weight gain as an impact experienced by some patients as a result of reduced physical activity following their ankle fracture. However, this was raised in the context of health and fitness rather than an aesthetic impact. Health professionals infrequently identified difficulty for their patients in wearing preferred footwear in the immediate post ankle fracture period. It was stated by one health professional that those patients who suffered an ankle fracture "may not be able to wear high heeled shoes" (hp1).

Theme 8: Medication Taking

Comments in this theme included impacts relating to medication usage. Both patients and health professionals infrequently reported responses that were grouped into this category. Descriptions of life impacts reported in this theme tended to be focused on pain medication usage in the first few months after the ankle fracture and plaster removal. However, some comments grouped into this theme were also mentioned in the context of sleeping (Table 3).