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Ankle Fractures

See also Fractures / Broken Bones

An ankle fracture (or “broken ankle”) is a break or multiple breaks in one or more of the bones in the ankle joint. In the short term, it is painful and temporarily disabling. In the long term, if not properly treated, a broken ankle can lead to significant complications and debility.

Ankle fractures are usually caused by a rotational injury (twisting or rolling) of the ankle, but can also be caused by an impact, such as from a fall.

Anatomy of the Ankle Joint

The ankle joint is composed of the three bones – the tibia (shinbone), the fibula (outer ankle bone), and the talus (which is the bone that connects your leg to your foot).

Graphic showing bones of the ankle.
Skeletal anatomy of the ankle

Ligaments connect bone to bone to provide stability of the joints. They are commonly injured in the case of ankle sprains. They can also be injured in connection with ankle fractures. When ligaments are torn and associated with an ankle fracture, this damage can render the ankle unstable. The deltoid ligament is found on the inner part of the ankle and provides the majority of the stability of the ankle. If the deltoid ligament is torn in association with a fracture, the ankle is generally unstable.

In the ankle joint or any joint in the body, two or more bones move relative to one another. There is a cushion or lining between the bones, which is called cartilage. Thinning or damage to this cushion can lead to arthritis or inflammation in the joint.

Types of Ankle Fractures

We think of the ankle as having three sides and a roof, and fractures can occur in each of these areas or in combination.

  • The most common fracture occurs at the knobby bump on the outside of the ankle at the bottom of the fibula, which is called the lateral malleolus.
  • The second most common type involves both the lateral malleolus and the medial malleolus (the knobby bump on the inside of the ankle at the bottom of the tibia). This is called a bimalleolar ankle fracture, since it involves two sides.
  • When the fracture involves the inside (medial), outside (lateral) and back (posterior) of the ankle, it is called a trimalleolar ankle fracture, since it involves all three sides of the ankle.
  • A fracture through the weightbearing “roof” of the ankle, is referred to as a pilon or plafond fracture. This is usually a higher energy injury caused from a fall from a height.

As the number of fracture lines increase, so does the risk of long-term joint damage. Trimalleolar ankle fractures and pilon fractures have the most cartilage injury and, therefore, have a higher risk of arthritis in the future.

Within each type, the fracture may be either nondisplaced (bones are broken but still in correct position and alignment) or displaced (fractured portions of bone are separated or misaligned). Treatment will be based on fracture alignment and stability of the ankle.

There are some additional, unique types of fractures.

A Maisonneuve fracture, for example, involves a complete disruption of the ligaments around the ankle associated with a fracture of the fibula at the level of the knee. For this type of injury, an ankle X-ray may not show a fracture or demonstrate the instability associated with this injury, because the actual bone fracture is well above the ankle, and the ligament injuries can only be seen with other forms of imaging, such as an MRI.

X-ray image showing front view of a bimalleolar fracture with mild displacement.
X-ray image showing front view of a bimalleolar fracture

X-ray image showing side view of a displaced lateral malleolus fracture of the right foot.
X-ray image showing side view of a displaced lateral malleolus fracture of the right ankle

 

Symptoms and Diagnosis

The most common symptoms of an ankle fracture are pain and swelling, either of which may be present only in the ankle region itself or spread to parts of the foot or up toward the knee. Any pain will usually be more intense if the injured person tries to put weight on the ankle. Contusions (bruises) are also usually present. In a severe break, the ankle may appear to be deformed or have bone protruding out of the skin.

X-rays are usually required to determine whether there is a broken bone as opposed to a soft-tissue injury like a sprain, since ankle sprains and breaks have similar symptoms. Other radiology imaging, such as a CT scan or MRI, may be needed to determine the full scope of the injury.

If the imaging shows that a person has a fractured ankle, he or she should consult an orthopedic surgeon as soon as possible. There are several different types of ankle breaks, and not all require surgery. But when they do, it is important that they receive the appropriate surgery by a skilled foot and ankle specialist. An inappropriate or poorly executed surgery can lead a patient to require additional corrective surgeries and/or, years later, to develop ankle instability, arthritis or even the need for an ankle replacement operation. Early and correct intervention is the key to preserving the ankle joint over the long term.

X-ray image showing front view of a displaced fibula with medial clear space widening (asymmetry of the joint space) indicating a deltoid ligament disruption.
X-ray showing front view of a displaced fibula with medial clear space widening (asymmetry of the joint space) indicating a deltoid ligament disruption

X-ray image showing side view of a displaced fibula fracture with a posterior malleolar fracture.
X-ray showing side view of a displaced fibula fracture with a posterior malleolar fracture

 

Treatment

Treatment is based on the alignment of the bones and the stability of the ankle joint. The goal is to have the bones heal as closely to perfect as possible so as to prevent any residual instability or malalignment of the bone. A malalignment of as little as two millimeters in the ankle joint can lead to arthritis. It is much easier to fix a fracture than to treat arthritis in the future. Certain mild ankle breaks (stable and with no displacement) can be treated nonsurgically with a splint, short leg cast, or other protective device such as a walking boot Some patients may be able to walk immediately while wearing a support while others may have to use crutches to limit weightbearing.

For more serious fractures in which bones or bone fragments are misaligned, surgical intervention is necessary to prevent improper healing (malunion) that would impede proper movement in the ankle and possibly lead to other complications.

X-ray image of surgical plates and screws to treat a trimalleolar fracture
X-ray showing front view of surgical plates and screws to treat a trimalleolar fracture

X-ray image showing side view of surgical plates and screws to treat a the trimalleolar fracture
X-ray showing side view of the same

 

X-ray image showing front view of fixation of the fibula and posterior malleolus with restoration of the joint congruity.
X-ray showing front view of fixation of the fibula and posterior malleolus with restoration of the joint congruity

X-ray image showing side view of fixation of the fibula and posterior malleolus with restoration of the joint congruity.
X-ray showing side view of the same

 

Recovery

It takes about six weeks for bones to heal. It may take longer for ligaments or other soft tissues to heal as well.

After surgery, patients are typically not weightbearing for 4 to 6 weeks until the bone heals. Patients are placed on a pain management protocol that minimizes their need for opioid medications. For the first couple of weeks, patients are in a splint and are elevating the limb 90% of the day. After 10 to 14 days, the sutures are removed and patients are typically placed into a removable boot. This allows patients to start moving the ankle and to shower. At the six-week visit, X-rays are obtained. Assuming the bone is healed well, patients are then allowed to start weightbearing and to begin physical therapy. Patients will generally have six weeks of therapy or more if required.

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