Ankle Fracture (Broken Ankle) Education

A broken ankle is often referred to as an ankle "fracture." This means that at least one of the bones that make up the ankle joint are broken.

A fractured ankle may range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may necessitate that you not put body weight on it for several months.

Putting it simple, the more bones which are broken, the more unstable the ankle ends up being. There may be ligaments damaged also. The ligaments of the ankle hold the ankle bones and joint in place.

Broken ankles impact individuals of any age. In the past 30 to 40 years, doctors have noted an increase in the number and severity of broken ankles, due to some extent to an active, elderly population of "baby boomers."

Anatomy

Three bones constitute the ankle joint:

•   Tibia - shinbone

•   Fibula - smaller bone of the lower leg

•   Talus - a small bone that sits between the heel bone (calcaneus) and the tibia and fibula

The tibia and fibula have specified parts that constitute the ankle:

•   Medial malleolus - within part of the tibia

•   Posterior malleolus - back portion of the tibia

•   Lateral malleolus - end of the fibula

Doctors classify ankle fractures based on the area of bone that's broken. For instance, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both the tibia and fibula are broken, it's called a bimalleolar fracture.

Two joints are involved in ankle fractures:

•   Ankle joint - where the tibia, fibula, and talus meet

•   Syndesmosis joint - the joint between the tibia and fibula, which is held together by ligaments

Multiple ligaments help make the ankle joint stable.

Cause

•   Turning or rotating your ankle

•   Rolling your ankle

•   Tripping or falling

•   Impact during a vehicle accident

Symptoms

Because a serious ankle sprain can feel the same as a broken ankle, every ankle injury needs to be evaluated by a doctor.

Common symptoms for a broken ankle include:

•   Instant and serious pain

•   Swelling

•   Bruising

•   Tender to touch

•   Can't put any weight on the injured foot

•   Deformity ("out of place"), especially if the ankle joint is dislocated too

Doctor Examination

Medical History and Physical Examination

After talking about your medical history, symptoms, and how the injury occurred, your physician will do a careful examination of your ankle, foot, and lower leg.

Imaging Tests

If your physician suspects an ankle fracture, he or she will order additional tests to provide more information regarding your injury.

X-rays. X-rays are the most prevalent and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there's displacement (the gap between broken bones). They can also show what number of pieces of broken bone there are. X-rays may be taken of the leg, ankle, and foot to ensure nothing else is hurt.

Stress test. Depending on the kind of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, known as a stress test. This x-ray is done to see if certain ankle joint fractures call for surgery.

Computed tomography (CT) scan. This kind of scan can create a cross-section image of the ankle and is sometimes done to further assess the ankle injury. It is especially useful when the fracture extends into the ankle joint.

Magnetic resonance imaging (MRI) scan. These tests provide high resolution images of both bones and soft tissues, such as ligaments. For some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.

Treatment: Lateral Malleolus Fracture

A lateral malleolus fracture is a fracture of the fibula.

There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.

Nonsurgical Treatment

You might not require surgery if your ankle is stable, meaning the broken bone is not out of place or just barely out of place. A stress x-ray may be done to see if the ankle is stable. The kind of treatment required can also be based on where the bone is broken.

A number of different methods can be used for protecting the fracture while it heals, ranging from a high-top tennis shoe to a short leg cast. Some physicians let patients put weight on their leg straight away, while others ask them to wait for 6 weeks.

You will see your physician regularly to repeat your ankle x-rays to make sure the fragments of your fracture haven't moved out of place during the healing process.

Surgical Treatment

If the fracture is out of place or your ankle is unstable, your fracture may be treated with surgery. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. They're held together with special screws and metal plates connected to the outer surface of the bone. In some cases, a screw or rod inside the bone can be used to keep the bone fragments together while they heal.

Treatment: Medial Malleolus Fracture

A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures can occur at different levels of the medial malleolus.

Medial malleolar fractures often take place with a fracture of the fibula (lateral malleolus), a fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle ligaments.

Nonsurgical Treatment

If the fracture is not out of place or is a very low fracture with very small pieces, it may be treated without surgery.

A stress x-ray may be done to see if the fracture and ankle are stable.

The fracture might be treated with a short leg cast or a removable brace. Usually, you need to avoid putting weight on your leg for approximately 6 weeks.

You will need to see your physician regularly for repeat x-rays to make sure the fracture doesn't change in position.

Surgical Treatment

If the fracture is out of place or the ankle is unstable, surgery might be advisable.

In many cases, surgery may be considered even if your fracture is not out of place. This is done to reduce the risk of the fracture not healing (known as a nonunion), and to allow you to begin moving the ankle earlier.

A medial malleolus fracture can include impaction or indenting of the ankle joint. Impaction occurs when a force is so great it drives the end of one bone into another one. Repairing an impacted fracture may necessitate bone grafting. This graft acts as a scaffolding for new bone to grow on, and might reduce any later risk of developing arthritis.

Depending on the fracture, the bone fragments might be fixed using screws, a plate and screws, or different wiring techniques.

Treatment: Posterior Malleolus Fracture

A posterior malleolus fracture is a fracture of the rear of the tibia at the level of the ankle joint.

In many cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken. This is because it shares ligament attachments with the posterior malleolus. There could also be a fracture of the medial malleolus.

Based on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and ought to be treated with surgery.

It is important for a posterior malleolus fracture to be diagnosed and treated properly because of the risk for developing arthritis. The rear of the tibia where the bone breaks is protected with cartilage. Cartilage is the smooth surface that lines a joint. If the broken piece of bone is larger than about 25% of your ankle, and is out of place more than a couple of millimeters, the cartilage surface will not heal properly and the surface of the joint will not be smooth. This uneven surface usually leads to increased and uneven pressure on the joint surface, leading to cartilage damage and the advancement of arthritis.

Nonsurgical Treatment

If the fracture isn't out place and the ankle is stable, it may be treated without surgery.

Treatment may be with a short leg cast or a removable brace. Patients are usually advised not to put any weight on the ankle for 6 weeks.

Surgical Treatment

If the fracture is out of place or if the ankle joint is unstable, surgery may be offered.

Different surgical options are available for dealing with posterior malleolar fractures. One choice is to have screws placed from the front of the ankle to the back, or vice versa. Another choice is to have a plate and screws put along the back of the shin bone.

Treatment: Bimalleolar Fractures or Bimalleolar Equivalent Fractures

"Bi" means two. "Bimalleolar" means that two of the three parts or malleoli of the ankle are broken. (Malleoli is plural for malleolus.)

In many instances of bimalleolar fracture, the lateral malleolus and the medial malleolus are broken and the ankle isn't stable.

A "bimalleolar equivalent" fracture means that along with one of the malleoli being fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.

A stress test x-ray may be done to see whether the medial ligaments are injured.

Bimalleolar fractures or bimalleolar equivalent fractures are volatile fractures and can be associated with a dislocation.

Nonsurgical Treatment

These injuries are considered unstable and surgery is typically recommended.

Nonsurgical treatment may be considered if you have significant health problems, where the risk of surgery may be too great, or if you generally don't walk.

Immediate treatment typically features a splint to immobilize the ankle until the swelling goes down. A short leg cast is then applied. Casts may be changed frequently as the swelling subsides in the ankle.

You will need to see your doctor regularly to repeat your x-rays to ensure that your ankle remains stable.

In most cases, Weightbearing isn't allowed for about six weeks. After 6 weeks, the ankle may be protected by a removable brace as it continues to heal.

Surgical Treatment

Surgical treatment is frequently recommended because these fractures make the ankle unstable.

Lateral and medial malleolus fractures are addressed with the same surgical techniques as written above for each fracture listed.

Treatment: Trimalleolar Fractures

"Tri" means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.

Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

As with bimalleolar ankle fractures, nonsurgical treatment may be considered if you have considerable health problems, where the danger of surgery may be too great, or if you usually don't walk.

Nonsurgical treatment is similar to bimalleolar fractures, as described above.

Surgical Treatment

Each fracture can be treated with the same surgical techniques as written above for each individual fracture.

Treatment: Syndesmotic Injury

The syndesmosis joint is located between the tibia and fibula, and is held together by ligaments. A syndesmotic injury may be just to the ligament -- this is also known as high ankle sprain. Depending on how unstable the ankle is, these injuries may be treatable without surgery. However, these sprains take longer to heal than the normal ankle sprain.

In many cases, a syndesmotic injury includes both a ligament sprain and one or more fractures. These are unstable injuries and they do very poorly without surgical treatment.

Your physician may do a stress test x-ray to see whether the syndesmosis is injured.

Outcome

Since there is such a wide range of injuries, there is also a wide range of how people heal following their injury.

It can take at least 6 weeks for the broken bones to heal. It might take longer for the involved ligaments and tendons to heal.

As outlined above, your doctor will most likely monitor the bone healing with repeated x-rays. This is normally done more often during the first 6 weeks if surgery is not selected.

Although most people return to normal daily activities, excluding sports, within three or four months, studies show that people can still be recovering up to two years after their ankle fractures. It may take several months for you to stop limping as you walk, and before you are able to return to sports at your previous competitive level. Most people return to driving within 9 to 12 weeks from when they were injured.

Rehabilitation

Rehabilitation is critical regardless of how an ankle fracture is addressed.

When your doctor lets you start moving your ankle, physical therapy and home exercise programs are very important. Doing your exercises regularly is key.

Eventually, you'll also start doing strengthening exercises. It might take several months for the muscles around your ankle to get sufficiently strong for you to walk without a limp and to return to your day to day activities.

Again, exercises only make a difference if you really do them.

Weightbearing

Your particular fracture determines when you can start putting weight on your ankle. A physician will let you start putting weight on your ankle whenever he or she feels your injury is steady enough to do so.

It is crucial to not put weight on your ankle until your physician says you can. If you put weight on the injured ankle too early, the fracture fragments may move or your surgery may fail and you might have to start over.

Supports

It is very common to have several different kinds of things to wear on the injured ankle, depending on the injury.

Initially, most ankle fractures are placed in a splint to protect your ankle and allow for the swelling to go down. After that, you might be put into a cast or removable brace.

Even following the fracture has healed, your doctor may recommend wearing an ankle brace for several months while you are doing sporting activities.

Complications

People who smoke, have diabetes, or are elderly are at a greater risk for complications after surgery, like problems with wound healing. This is because it might take longer for their bones to heal.

Nonsurgical Treatment

Without surgery, there is a risk that the fracture will move out of place before it heals. This is why it is important to follow up with your doctor as scheduled.

If the fracture fragments do get out of place and the bones heal in that position, it's called a "malunion." Treatment for this is determined by how far out of place the bones are and how the stability of the ankle joint is affected.

If a malunion does occur or if your ankle gets unstable after it heals, this can ultimately lead to arthritis in your ankle.

Surgical Treatment

General surgical risks include:

•   Infection

•   Bleeding

•   Pain

•   Blood clots in your leg

•   Damage to blood vessels, tendons, or nerves

Risks from the surgical treatment of ankle fractures include:

•   Difficulty with bone healing

•   Arthritis

•   Pain from the plates and screws which are used to fix fracture. Some patients choose to have them removed several months after their fracture heals

What to Discuss With Your Orthopaedic Surgeon:

•   When will I be able to begin putting weight on my leg?

•   How long will I be off of work?

•   Do I have any particular risks for not doing well?

•   If I have to have surgery, what are the risks?

•   Do I have weak bones?

Dr. Kathleen Weaver at Audrain Orthopaedics in Mexico, Missouri has experience diagnosing and finding answers for many conditions, including ankle fractures. If you have any questions, contact Dr. Weaver's office at 573-582-0444.

Thank you for seeing me the day I walked into your office in such pain – I believe that there are angels among us & you were mine that day…

N.M age 59