Beyond splinting: evidence-based strategies for prehospital ankle fracture management – A systematic review

Background: Ankle fractures are common injuries that often present first to general practitioners, urgent care clinicians, or emergency medical services (EMS) teams. Inadequate prehospital management such as suboptimal splinting, missed neurovascular compromise, or delayed referral can lead to fracture displacement, soft tissue complications, and surgical delays. This systematic review evaluates current evidence on prehospital management of ankle fractures with emphasis on the roles of family physicians and first-contact providers. It proposes evidence-based recommendations for assessment, immobilisation, and referral that align with orthopaedic goals. Methods: A literature search was conducted using PubMed from 2000 to 2025. Relevant studies on splinting, external fixation, fracture-dislocation management, and EMS/primary care protocols were selected and synthesised. Results: Comparative studies reveal that splinting in fracture-dislocations is associated with high rates of displacement and soft tissue compromise, whereas temporary external fixation demonstrates superior outcomes. Splint quality audits reveal widespread errors in initial immobilisation. National EMS and primary care guidelines lack specificity on prehospital ankle fracture management. Conclusion: Family medicine and emergency providers play a crucial role in ankle fracture outcomes. This review presents a protocol to improve early fracture care through orthopaedic-informed immobilisation, repeat neurovascular checks, analgesia, open wound coverage, and timely referral. Integration into EMS and primary care education is recommended.