HMN 2026: How People with unstable ankle fractures may avoid surgery and do well with casts

Ankle fractures are among the most common fractures in adults. Some ankle fractures are “stable,” so the patient can carry on walking on the ankle without the bones falling out of position. However, some fractures are “unstable” and require more support, sometimes even involving surgery. More than 20,000 people are admitted to hospitals in England each year with an unstable ankle fracture. The best way of treating unstable ankle fractures is an important area of research, for both patients and health care systems.

In an editorial piece published in BMJ, NDORMS Professors David Keene and Matthew Costa commend a new clinical trial that advances the understanding of ankle fracture treatment.

The SUPER-FIN trial, conducted at a specialist university hospital trauma center in Finland, compared non-surgical treatment in a cast for six weeks with surgery for patients with an unstable fracture of the ankle. The study found that people treated with a cast reported similar outcomes to those having surgery but had fewer treatment-related harms.

Reviewing the trial in BMJ Prof. Keene, Kadoorie professor of trauma rehabilitation at NDORMS said, “In the past decade, a growing number of randomized controlled trials have assessed the effectiveness of interventions for ankle fracture management. For example, early versus late weight bearing after surgery for unstable fractures. Or, the use of casting versus a walking boot. Collectively, these randomized controlled trials are supporting much needed advances in the evidence base for ankle fracture management.”

Prof. Costa, professor of orthopedic trauma at NDORMS said, “The SUPER-FIN team are to be congratulated for conducting a robust study that addresses an important clinical question. The trial adds to a growing body of evidence that will guide the management of ankle fractures and will support treatment decisions and updates to clinical guidelines. These randomized controlled trials are a fantastic example of how trauma and orthopedic health professionals, researchers, and patient participants can work together to improve outcomes for patients with common injuries.”

The Oxford Trauma research group at the newly formed Kadoorie Institute of Trauma, Emergency and Critical Care within NDORMS, are currently completing two large-scale randomized controlled trials on ankle fracture management. These trials are investigating surgery and non-surgical management (FAME) and modes of rehabilitation (AFTER), with results due for publication later this year.

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