Ankle Fracture

Overview

The ankle joint is a critical weight-bearing structure that allows for movement between the leg and foot. It consists of three main bones: the tibia (shinbone), the fibula (smaller bone on the outside of the leg), and the talus (a bone in the foot). These bones are held together by strong ligaments and form a stable joint that supports body weight during walking, running, and jumping.

Ankle fractures can involve one, two, or all three of these bones. The most common types include lateral malleolus fractures (involving the fibula), medial malleolus fractures (involving the tibia), and posterior malleolus fractures (involving the back part of the tibia). When two or more areas are fractured, it's called a bimalleolar or trimalleolar fracture, which typically requires more complex treatment.

The severity of ankle fractures is classified using various systems, with the most common being the Weber classification for fibular fractures and the Lauge-Hansen classification based on the mechanism of injury. Stable fractures typically involve a single bone without significant displacement, while unstable fractures involve multiple bones or significant displacement and may require surgical intervention.

Ankle fractures are among the most common orthopedic injuries, accounting for approximately 9% of all fractures. They affect people of all ages but show different patterns in different age groups. Young adults often sustain high-energy fractures from sports or motor vehicle accidents, while older adults more commonly experience low-energy fractures from simple falls due to age-related bone weakness.

Symptoms

The symptoms of ankle fractures can vary significantly depending on the severity of the injury, the number of bones involved, and whether the fracture is displaced. Some symptoms may be similar to those of severe ankle sprains, making accurate diagnosis important.

Immediate Symptoms

• Ankle pain - severe, immediate pain at the time of injury
• Ankle swelling - rapid onset of swelling around the ankle joint
• Ankle weakness - inability to move the ankle normally
• Inability to bear weight or walk on the affected leg
• Visible deformity if the fracture is displaced
• Bruising around the ankle and foot

Associated Pain Patterns

• Leg pain - pain extending up the leg from the ankle
• Foot or toe pain - pain radiating into the foot
• Knee weakness - compensatory weakness from altered gait
• Tenderness over specific bone areas
• Pain with attempted movement of the ankle

Physical Signs

• Foot or toe swelling - swelling extending into the foot
• Bruising (ecchymosis) that may develop over hours to days
• Crepitus - a grating sensation when bones rub together
• Instability when attempting to move the ankle
• Numbness or tingling if nerves are affected
• Pallor or coolness if blood vessels are injured

Functional Limitations

• Complete inability to bear weight (non-weight bearing)
• Inability to push off with the affected foot
• Difficulty or inability to wear shoes
• Altered walking pattern or limping
• Difficulty with stairs or uneven surfaces

Warning Signs of Complications

• Severe, unrelenting pain despite treatment
• Loss of sensation in the foot or toes
• Color changes in the foot (blue, white, or mottled)
• Inability to move toes or foot
• Signs of infection if skin is broken
• Increasing swelling despite elevation and ice

Chronic Symptoms

If untreated or improperly treated, ankle fractures may lead to:

• Chronic ankle pain and stiffness
• Arthritis in the ankle joint
• Recurrent ankle instability
• Difficulty with activities requiring ankle mobility
• Muscle weakness and atrophy

Causes

Ankle fractures result from forces applied to the ankle that exceed the strength of the bone. The mechanism of injury often determines the pattern and severity of the fracture. Understanding these mechanisms helps in both prevention and treatment planning.

High-Energy Trauma

These mechanisms typically result in more severe, often unstable fractures:

• Motor vehicle accidents: High-impact collisions causing complex fracture patterns
• Falls from height: Landing on feet from significant height
• High-velocity sports injuries: Skiing, snowboarding, or high-impact sports
• Motorcycle accidents: Direct impact or crushing injuries
• Industrial accidents: Heavy machinery or falling objects

Low-Energy Trauma

More common in older adults or those with weakened bones:

• Simple falls: Tripping over objects or losing balance
• Twisting injuries: Stepping in holes or on uneven surfaces
• Slipping accidents: On ice, wet surfaces, or stairs
• Minor stumbles: Especially in those with osteoporosis

Sports-Related Mechanisms

• Inversion injuries: Ankle rolls inward excessively
  • Landing on someone's foot in basketball
  • Stepping in holes during running
  • Losing balance on uneven terrain
• Eversion injuries: Ankle rolls outward forcefully
• Axial loading: Force applied along the length of the leg
  • Landing from jumps with poor technique
  • Compression fractures from high-impact landing
• Rotational injuries: Twisting while foot is planted

Mechanism-Specific Fracture Patterns

• Supination-external rotation: Most common mechanism, typically causing spiral fibular fractures
• Pronation-external rotation: Results in oblique fibular fractures with medial injury
• Supination-adduction: Causes transverse fibular fractures or medial malleolus fractures
• Pronation-abduction: Results in horizontal fibular fractures with deltoid ligament injury

Pathological Fractures

Fractures occurring through diseased bone:

• Osteoporosis-related fractures
• Bone tumors or metastases
• Bone infections (osteomyelitis)
• Metabolic bone diseases
• Stress fractures from repetitive loading

Age-Related Factors

• Children and adolescents:
  • Growth plate injuries (Salter-Harris fractures)
  • More flexible bones that may bend rather than break
  • Sports-related injuries more common
• Adults:
  • Complete fractures through mature bone
  • Work-related or recreational injuries
• Elderly:
  • Lower energy needed due to bone weakness
  • Simple falls causing complex fractures
  • Higher risk of complications

Risk Factors

Various factors can increase the likelihood of sustaining an ankle fracture. Some are modifiable through lifestyle changes, while others are inherent characteristics that require awareness and appropriate precautions.

Bone-Related Risk Factors

• Osteoporosis: Decreased bone density making bones more fragile
  • Post-menopausal women at highest risk
  • Men over 70 also at increased risk
  • Requires lower force to cause fractures
• Age: Bone strength decreases with aging
• Previous fractures: History of bone breaks indicates bone weakness
• Metabolic bone diseases: Conditions affecting bone metabolism
• Vitamin D deficiency: Leads to weakened bone structure

Activity and Lifestyle Factors

• Sports participation: Especially high-risk activities
  • Basketball, football, soccer
  • Skiing, snowboarding, skateboarding
  • Running, particularly trail running
  • Gymnastics and dance
• Occupational hazards:
  • Construction work
  • Jobs requiring ladder use
  • Industrial work with heavy machinery
  • Emergency services personnel
• Physical activity level: Both extremes carry risks
  • Sedentary lifestyle leading to bone weakness
  • Excessive activity increasing injury risk

Medical Conditions

• Previous ankle injuries: Sprains or fractures causing instability
• Arthritis: Joint degeneration affecting stability
• Neurological conditions:
  • Conditions affecting balance and coordination
  • Peripheral neuropathy reducing sensation
  • Muscle weakness disorders
• Vision problems: Increasing fall risk
• Medications: Affecting balance or bone strength
  • Corticosteroids weakening bones
  • Sedatives affecting coordination
  • Blood pressure medications causing dizziness

Environmental Risk Factors

• Weather conditions:
  • Ice and snow increasing slip risk
  • Wet surfaces causing falls
  • Poor visibility conditions
• Footwear:
  • High heels increasing instability
  • Worn shoe treads reducing traction
  • Improper fitting shoes
  • Inadequate support for activities
• Environmental hazards:
  • Uneven walking surfaces
  • Poor lighting conditions
  • Cluttered walkways
  • Missing handrails on stairs

Demographic Factors

• Gender:
  • Women: Higher risk due to osteoporosis
  • Men: Higher risk of high-energy trauma
• Age distribution:
  • Bimodal distribution: peaks in young adults and elderly
  • Different mechanisms in different age groups

Protective Factors

• Regular weight-bearing exercise
• Adequate calcium and vitamin D intake
• Proper footwear for activities
• Home safety modifications
• Balance and strength training
• Vision correction when needed

Diagnosis

Accurate diagnosis of ankle fractures is crucial for proper treatment and optimal outcomes. The diagnostic process involves clinical evaluation, imaging studies, and sometimes specialized tests to determine the extent of injury and guide treatment decisions.

Clinical Assessment

History Taking

• Mechanism of injury: How the injury occurred
• Pain characteristics: Location, severity, and quality
• Functional limitations: Ability to bear weight or walk
• Previous ankle injuries: History of sprains or fractures
• Medical history: Osteoporosis, medications, bone diseases
• Activity level: Sports participation, occupation

Physical Examination

• Inspection:
  • Visible deformity or bone protrusion
  • Swelling patterns and severity
  • Bruising location and extent
  • Skin integrity and open wounds
• Palpation:
  • Bone tenderness at specific locations
  • Soft tissue swelling and warmth
  • Pulse assessment for vascular injury
  • Crepitus indicating bone fragments
• Range of motion:
  • Active and passive ankle movement
  • Pain with attempted motion
  • Stability testing (if appropriate)

Ottawa Ankle Rules

Clinical decision rules to determine when X-rays are needed:

• Ankle X-rays required if:
  • Bone tenderness at posterior edge or tip of lateral malleolus
  • Bone tenderness at posterior edge or tip of medial malleolus
  • Inability to bear weight both immediately and in emergency department
• Foot X-rays required if:
  • Bone tenderness at base of 5th metatarsal
  • Bone tenderness at navicular bone
  • Inability to bear weight both immediately and in emergency department

Imaging Studies

Plain Radiographs (X-rays)

First-line imaging for suspected ankle fractures:

• Standard views:
  • Anteroposterior (AP) view
  • Lateral view
  • Mortise view (15-20 degree internal rotation)
• Information provided:
  • Fracture location and pattern
  • Degree of displacement
  • Joint alignment and congruity
  • Presence of bone fragments

Computed Tomography (CT)

• Used for complex fractures requiring surgical planning
• Better visualization of articular surface involvement
• Assessment of bone fragment displacement
• 3D reconstruction for surgical planning
• Evaluation of posterior malleolus fractures

Magnetic Resonance Imaging (MRI)

• Excellent soft tissue visualization
• Assessment of ligament injuries
• Detection of bone marrow edema
• Evaluation of cartilage damage
• Useful for suspected stress fractures

Classification Systems

Weber Classification (Fibular Fractures)

• Weber A: Below syndesmosis, usually stable
• Weber B: At syndesmosis level, may be unstable
• Weber C: Above syndesmosis, usually unstable

Lauge-Hansen Classification

Based on foot position and direction of force:

• Supination-external rotation (most common)
• Supination-adduction
• Pronation-external rotation
• Pronation-abduction

Special Considerations

• Pediatric patients: Growth plate assessment required
• Open fractures: Immediate surgical consultation needed
• Neurovascular injury: Urgent evaluation for compartment syndrome
• Diabetic patients: Risk of complications and delayed healing

Differential Diagnosis

Conditions that may mimic ankle fractures:

• Severe ankle sprain
• Ankle dislocation without fracture
• Achilles tendon rupture
• Stress fractures
• Osteochondral injuries
• Soft tissue contusions

Treatment Options

Treatment of ankle fractures depends on several factors including fracture pattern, stability, displacement, patient age, activity level, and overall health. The primary goals are to restore ankle anatomy, maintain joint stability, and optimize functional outcomes while minimizing complications.

Emergency Management

Immediate Care

• RICE protocol:
  • Rest: Avoid weight bearing on injured ankle
  • Ice: Apply ice packs for 15-20 minutes every 2-3 hours
  • Compression: Elastic bandage to control swelling
  • Elevation: Keep ankle elevated above heart level
• Immobilization: Splinting for comfort and protection
• Pain management: Appropriate analgesics
• Neurovascular assessment: Check circulation and nerve function

Non-Surgical Treatment

Indications for Conservative Management

• Stable, non-displaced fractures
• Weber A fractures (below syndesmosis)
• Isolated medial malleolus fractures without displacement
• Patients unfit for surgery
• Minimally displaced fractures in elderly patients

Immobilization Methods

• Short leg cast:
  • Below-knee plaster or fiberglass cast
  • Typical duration: 6-8 weeks
  • Non-weight bearing initially
  • Graduated weight bearing as healing progresses
• Walking boot (CAM walker):
  • Removable protective boot
  • Allows for gradual mobilization
  • Easier for hygiene and therapy
  • Used for stable fractures
• Ankle brace:
  • For very stable fractures
  • Provides support while allowing some motion

Surgical Treatment

Indications for Surgery

• Displaced fractures (>2mm displacement)
• Unstable fracture patterns
• Weber B or C fractures with instability
• Bimalleolar or trimalleolar fractures
• Open fractures
• Fractures with joint incongruity
• Failed non-operative treatment

Surgical Techniques

• Open reduction and internal fixation (ORIF):
  • Plates and screws for fibular fractures
  • Screws or tension band for medial malleolus
  • Posterior malleolus fixation if >25% of joint
  • Syndesmotic screw if ligament torn
• Percutaneous fixation:
  • Minimally invasive screw placement
  • Used for certain fracture patterns
  • Reduced soft tissue trauma
• External fixation:
  • Reserved for severe open fractures
  • Temporary stabilization
  • Severe soft tissue damage cases

Post-Treatment Management

Weight Bearing Progression

• Non-weight bearing: 0-6 weeks (varies by fracture)
• Partial weight bearing: Gradual increase with healing
• Full weight bearing: When clinical and radiographic healing complete

Rehabilitation

• Early phase (0-6 weeks):
  • Pain and swelling management
  • Maintain range of motion in other joints
  • Isometric exercises if appropriate
• Intermediate phase (6-12 weeks):
  • Begin range of motion exercises
  • Progressive weight bearing
  • Strengthening exercises
• Advanced phase (3-6 months):
  • Advanced strengthening
  • Balance and proprioception training
  • Activity-specific training
  • Return to sports preparation

Complications and Management

• Immediate complications:
  • Infection in open fractures
  • Neurovascular injury
  • Compartment syndrome
• Late complications:
  • Post-traumatic arthritis
  • Chronic pain and stiffness
  • Hardware problems
  • Nonunion or malunion

Return to Activity

• Timeline varies: 3-6 months for complete recovery
• Depends on fracture pattern and treatment method
• Sports return requires full strength and function
• Some patients may have permanent limitations
• Activity modification may be necessary

Prevention

While not all ankle fractures can be prevented, many strategies can significantly reduce the risk of injury. Prevention efforts should focus on addressing modifiable risk factors and creating safer environments for daily activities and sports participation.

Bone Health Optimization

• Calcium intake:
  • Adults: 1000-1200 mg daily
  • Dairy products, leafy greens, fortified foods
  • Supplements if dietary intake inadequate
• Vitamin D:
  • 600-800 IU daily for most adults
  • Sun exposure, fatty fish, fortified foods
  • Testing and supplementation as needed
• Weight-bearing exercise:
  • Walking, jogging, dancing, tennis
  • Resistance training to build bone density
  • Regular activity throughout life

Fall Prevention

Home Safety

• Environmental modifications:
  • Remove tripping hazards (rugs, cords, clutter)
  • Install adequate lighting, especially in stairs
  • Add handrails to staircases
  • Use non-slip mats in bathrooms
  • Keep walkways clear and well-maintained
• Outdoor safety:
  • Clear ice and snow from walkways
  • Use salt or sand for traction
  • Repair uneven sidewalks and driveways
  • Install motion-sensor lighting

Personal Strategies

• Balance and strength training:
  • Tai chi, yoga, or specific balance programs
  • Single-leg standing exercises
  • Core strengthening
  • Lower extremity strengthening
• Vision care:
  • Regular eye examinations
  • Update prescriptions as needed
  • Address vision problems promptly
• Medication management:
  • Review medications affecting balance
  • Avoid excessive alcohol consumption
  • Be cautious with sedating medications

Sports Injury Prevention

• Proper training:
  • Gradual increase in activity intensity
  • Sport-specific conditioning
  • Professional instruction for technique
  • Adequate rest and recovery
• Protective equipment:
  • Appropriate footwear for each activity
  • Ankle braces for high-risk sports
  • Proper protective gear
• Environmental awareness:
  • Inspect playing surfaces for hazards
  • Avoid activities in poor weather conditions
  • Use appropriate facilities and equipment

Footwear Considerations

• Daily wear:
  • Proper fit with adequate toe room
  • Good arch support
  • Non-slip soles
  • Low to moderate heel height
• Activity-specific:
  • Sport-appropriate shoes
  • Replace worn footwear regularly
  • Consider ankle support for high-risk activities

High-Risk Population Strategies

• Elderly individuals:
  • Regular medical check-ups
  • Bone density screening
  • Balance assessment and training
  • Medication review for fall risk
• Athletes:
  • Pre-participation physical examinations
  • Ankle stability and strength assessment
  • Previous injury rehabilitation completion
  • Proper warm-up and cool-down routines
• Osteoporotic patients:
  • Medical management of bone disease
  • Fall prevention programs
  • Hip protectors if appropriate
  • Regular monitoring and treatment

Workplace Safety

• Proper safety training and equipment
• Adherence to safety protocols
• Regular equipment maintenance
• Ergonomic workplace design
• Incident reporting and analysis

When to See a Doctor

Seek emergency medical attention immediately for:

• Severe ankle pain after trauma or injury
• Visible bone protruding through the skin (open fracture)
• Obvious deformity of the ankle or foot
• Complete inability to bear weight or move the ankle
• Numbness or tingling in the foot or toes
• Foot or toes that appear blue, white, or cold
• Loss of pulse in the foot
• Signs of infection if skin is broken

Seek urgent medical care for:

• Significant ankle swelling that develops rapidly
• Severe pain that doesn't improve with rest and over-the-counter pain medication
• Ankle weakness preventing normal walking
• Inability to bear weight on the ankle after 24-48 hours
• Persistent leg pain extending up from the ankle
• Signs that meet Ottawa Ankle Rules criteria

Schedule medical evaluation for:

• Persistent foot or toe pain after ankle injury
• Foot or toe swelling that doesn't improve with elevation
• Knee weakness developing after ankle injury
• Ankle pain or swelling that persists beyond expected healing time
• Recurrent ankle injuries or instability
• Difficulty returning to normal activities after treatment

Follow-up care is important for:

• Monitoring fracture healing progress
• Adjusting treatment plans as needed
• Physical therapy progression
• Return to work or sports clearance
• Hardware removal considerations
• Long-term complication prevention

Consider consultation for:

• Recurrent ankle injuries or chronic instability
• Persistent pain or stiffness after fracture healing
• Functional limitations affecting daily activities
• Athletes requiring sport-specific rehabilitation
• Complex fractures requiring specialized care

Related Conditions

• Ankle Sprain
• Foot Fracture
• Leg Fracture
• Ankle Dislocation
• Osteoporosis
• Arthritis

References

1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand. 1998;69(1):43-47.
2. Stiell IG, et al. Implementation of the Ottawa ankle rules. JAMA. 1994;271(11):827-832.
3. Michelson JD. Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg. 2003;11(6):403-412.
4. Egol KA, et al. Ankle fractures in the elderly: treatment and outcomes. J Bone Joint Surg Am. 2015;97(20):1688-1695.
5. SooHoo NF, et al. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am. 2009;91(5):1042-1049.