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Ankle Fracture in Patients With Diabetic Neuropathy
Patients with diabetes frequently present to the emergency department for reasons similar to those of patients without diabetes. Often, the patient will report a twisting injury to the ankle followed by pain, swelling, and an inability to ambulate. Emergency department treatment typically does not include a specific evaluation for neuropathy, vascular disease, or other factors known to increase morbidity after an ankle fracture in patients with diabetes. However, definitive treatment of these patients should include a thorough evaluation of known risk factors, especially the loss of protective sensation. The most important factor in the successful management of an acute fracture in a patient with diabetes is recognition of underlying peripheral neuropathy. Fixation of an ankle fracture in a patient with neuropathy should be more aggressive, using stronger implants and a more stable construct, than that of a standard ankle fracture. Early recognition of neuropathic changes is critical to successful surgical or nonsurgical treatment. Nonsurgical treatment can be considered in patients with diabetes who have acute, nondisplaced fractures and no evidence of ankle instability. In this scenario, total contact cast treatment should be used instead of a removable walker boot. Surgical treatment is indicated in the presence of instability or displacement of the fracture, or early Charcot changes.