Outcome of ankle fractures in children: an updated systematic review and meta-analysis

Low-risk ankle fractures in children are commonly managed with immobilisation, using options such as supportive bandages, removable boots/braces or casted devices. The aim of this study was to review the literature to determine the optimal treatment for these fractures.

A systematic review of randomised controlled trials (RCTs) was conducted in November 2024. Comprehensive searches of MEDLINE, Embase and Cochrane CENTRAL were performed. Studies recruiting children (0-18 years) with low-risk, stable or suspected occult ankle fractures managed non-operatively were included, comparing different immobilisation devices. Unscheduled returns to healthcare facilities, patient-reported outcomes, functional outcomes, and complication rates were assessed.

Seven RCTs involving 503 children were included. Compared with casts, removable boots/braces significantly reduced unscheduled healthcare visits (risk ratio [RR] 0.26; 95% confidence interval [CI] 0.13 to 0.52; p = 0.0001), shortened return to normal activities (mean difference [MD] -6.83 days; 95% CI -11.20 to -2.96; p = 0.0031), and improved functional scores (standardised mean difference [SMD] -0.79; 95% CI -1.03 to -0.55; p < 0.00001). Patient and parent satisfaction was also higher with removable devices. Supportive bandaging reduced missed school days (MD -0.49; 95% CI -0.81 to -0.18; p = 0.002) and accelerated return to baseline activities (14.17 vs 20.19 days; p = 0.0002), although results showed high heterogeneity. No significant differences were found in pain, complications, emotional wellbeing or mobility between groups.

Removable boots or braces offer a favourable alternative to cast immobilisation for low-risk paediatric ankle fractures. However, the necessity of rigid over soft immobilisation remains uncertain. A definitive RCT based on a core outcome set and cost-effective analyses is required to inform treatment recommendations.