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Ankle Fractures

Basics

  • Bones involved: tibia, fibula, talus.
  • Mortise joint: tibial plafond, fibula (medial/lateral malleoli), and talus.
  • Ligaments: syndesmotic, lateral collateral, medial collateral (deltoid).

Classification

Danis-Weber (based on fibular fracture level)

  • Type A (30%): below ankle joint; usually stable.
  • Type B (63%): at ankle joint level; may be stable or unstable.
  • Type C (7%): above ankle joint; usually unstable.

Lauge-Hansen (based on foot position and force direction)

  • Supination-adduction (SA).
  • Supination-external rotation (SER) — most common (40-75%).
  • Pronation-abduction (PA).
  • Pronation-external rotation (PER).

Stability-based classification

  • Stable: isolated lateral malleolar (Weber A/B) without talar shift and negative stress test; nondisplaced medial malleolar.
  • Unstable: bi- or trimalleolar; Weber C or lateral malleolar with medial injury and positive stress; lateral malleolar with talar shift; displaced medial malleolar.
  • Pilon fracture: tibial plafond fracture, unstable.
  • Maisonneuve fracture: proximal fibular fracture with ankle injury or ligament disruption, risk of peroneal nerve injury.

Epidemiology

  • 9% of adult and 5% of pediatric fractures.
  • Peak incidence females 45-64 years; males 8-15 years.
  • Incidence: 107 to 184 per 100,000 per year.

Etiology & Pathophysiology

  • Common causes: falls (38%), inversion injuries (32%), sports (10%).
  • Plantar flexion increases joint instability.
  • Axial loading can cause pilon fractures.

Risk Factors

  • Age, prior fracture, polypharmacy, intoxication.
  • Obesity, sedentary lifestyle.
  • Smoking, diabetes.
  • Slippery surfaces.

Prevention

  • Use nonslip, flat, protective footwear.
  • Fall precautions in elderly.

Associated Conditions

  • Usually isolated; 5% have associated ipsilateral lower limb fractures.
  • Ligamentous/cartilage injuries.
  • Tibiotalar or subtalar dislocation.
  • Other axial loading injuries.

Diagnosis

History

  • Injury mechanism, pain location, weight-bearing status.
  • History of prior ankle injury or surgery.
  • Tetanus immunization status.
  • Fall risk, especially in elderly.

Physical Exam

  • Inspect skin for open fractures.
  • Palpate point tenderness, including proximal fibula.
  • Neurovascular status and weight-bearing ability.
  • Assess ankle stability (anterior drawer, talar tilt, squeeze, external rotation stress tests).

Differential Diagnosis

  • Ankle sprain (including high ankle sprain).
  • Fractures of talus, 5th metatarsal, calcaneus.
  • Achilles tendon injury.

Diagnostic Tests

Imaging

  • Use Ottawa Ankle Rules (OAR) to guide imaging (sensitivity ~98-99%).
  • Obtain x-rays if tenderness over distal tibia/fibula, inability to bear weight, or foot bone tenderness.
  • Standard views: AP, lateral, mortise (15-25° internal rotation).
  • Stress views for instability (medial clear space widening).
  • Pediatric: Salter-Harris fractures consideration; avoid stress views.
  • CT for operative planning in complex or intra-articular fractures.
  • MRI rarely indicated except for chronic instability or occult fractures.
  • Ultrasound for soft tissue injuries.
  • Bone scan or MRI for stress fractures.

Treatment

General Measures

  • Immobilize with splint/cast; non-weight-bearing with crutches.
  • Ice and elevate to reduce swelling.
  • Closed fractures: assess stability for management.
  • Fracture dislocations require urgent reduction.
  • Postreduction neurovascular exam and x-rays.

Medications

  • NSAIDs and/or acetaminophen for pain control.
  • Ketorolac IM as initial analgesia.
  • Open fractures: tetanus booster, broad-spectrum antibiotics ASAP.

Referral

  • Neurovascular compromise, open fractures, unstable or displaced fractures, compartment syndrome require urgent orthopedic consult.
  • Routine fractures: orthopedic follow-up within 1 week if non-weight-bearing.

Additional Therapies

  • Nonoperative: cast immobilization; weight-bearing progressed gradually.
  • Open fractures require surgical debridement and repair within 24 hours.

Surgery

  • Open reduction and internal fixation (ORIF) preferred for unstable fractures and athletes.
  • External fixation for severe tissue injury or comminution.
  • Timing: emergent if neurovascular compromise; otherwise, delay 5+ days for swelling.
  • Recovery: typically 6-8 weeks.

Pediatric Considerations

  • Salter-Harris I & II: nonoperative unless displaced.
  • Distal tibia: long leg cast 4-6 weeks + short leg cast 2-3 weeks.
  • Distal fibula: splint or brace 3-4 weeks; short leg cast if displaced.
  • Limit reduction attempts due to growth plate risk.
  • Displaced Salter-Harris III/IV or Tillaux/triplane fractures ≥2 mm require ORIF.

Geriatric Considerations

  • Increased surgical risk, osteoporosis risks fixation failure.
  • Higher complications from surgery/anesthesia.

Admission Criteria

  • Emergency surgery, nonadherence, lack of support, associated injuries, concerning injury mechanism.

Ongoing Care

  • Orthopedic follow-up with serial x-rays.
  • In children, monitor for growth arrest lines.
  • Immobilize 4-6 weeks, then gradual weight-bearing.
  • Physical therapy referrals as needed.

Patient Education

  • Ice and elevate for 2-3 weeks.
  • Use assistive devices as instructed.
  • Care for splint/cast (avoid moisture).
  • Report worsening swelling, numbness, pain, or color change.

Prognosis

  • Good outcomes without surgery if stable.
  • Most return to activity in 3-4 months.
  • Older age correlates with poorer mobility outcomes.

Complications

  • Displacement or instability.
  • Delayed union, malunion, nonunion (0.9-1.9%).
  • Postsurgical wound complications, fixation loss.
  • Deep vein thrombosis.
  • Complex regional pain syndrome.
  • Infection (osteomyelitis).
  • Posttraumatic arthritis.
  • Growth arrest in children.