"Among older adults with an unstable ankle fracture the use of a modified casting technique known as close contact casting a molded belowknee cast with minimal padding resulted in similar functional outcomes at  months compared with surgery and with fewer wound complications and reduced intervention costs according to a study appearing in the October  issue of JAMA.  The number of older adults sustaining ankle fractures is increasing. Treatment of unstable fractures is either surgical or nonsurgical using externally applied casts. Neither method yields an entirely satisfactory outcome in older adults. Traditional casting techniques are associated with poor fracture alignment and healing as well as plasterrelated sores. Surgery is often complicated by poor implant fixation bone healing wound problems and infection. A modified casting technique has been developed close contact casting which uses minimal padding compared with traditional casting and achieves fracture reduction by distributing contact pressure by close anatomic fit. Keith Willett M.B.B.S. F.R.C.S. of the University of Oxford United Kingdom and colleagues randomly assigned  adults older than  years with acute unstable ankle fracture to surgery n   or casting n  . Casts were applied in the operating room under general or spinal anesthesia by a trained surgeon. Among the  adults average age  years  percent women who were randomized  percent completed the study. Nearly all participants  percent received assigned treatment  of   percent who initially received casting later converted to surgery. At  months casting resulted in measures of ankle function equivalent to that with surgery. Infection and wound breakdown were more common with surgery  percent vs  percent as were additional operating room procedures  percent vs  percent.  Radiologic malunion abnormal healing of a fracture was more common in the casting group  percent vs  percent for surgery. Casting required less operating room time compared with surgery. There were no significant differences in other secondary outcomes quality of life pain ankle motion mobility and patient satisfaction. Close contact casting was delivered successfully for most participants substantially reducing the number of patients requiring invasive surgical procedures at the outset and additional operations during a month period the authors write.  The researchers add that close contact casting may be an appropriate treatment for older adults with unstable ankle fracture. doi.jama.. the study is available preembargo to the media at the For the Media website Editors Note Please see the article for additional information including other authors author contributions and affiliations financial disclosures funding and support etc. Editorial Close Contact Casting vs Surgery for Unstable Ankle Fractures The results reported by Willett et al demonstrate that most unstable ankle fractures in older patients can be treated with a cast without the need for surgery writes David W. Sanders M.D. M.Sc. F.R.C.S.C. of Western University London Ontario Canada in an accompanying editorial. However many patients who were initially treated by casting subsequently required repeat casting or surgery. Further studies are needed to help identify which patients will not benefit from casting. Although close contact casting may be unfamiliar to some orthopedic surgeons it can avoid surgery for older patients with ankle fractures yet result in equivalent functional outcomes. This technique is worth considering when treating this challenging clinical problem. doi.jama.. the study is available preembargo to the media at the For the Media website Editors Note The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.   To place an electronic embedded link to these articles in your story These links will be live at the embargo time httpjama.jamanetwork.comarticle.aspxdoi.jama.. httpjama.jamanetwork.comarticle.aspxdoi.jama.."