Ankle fracture
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An ankle fracture is a break of one or more of the bones that make up the
ankle joint The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joi ...
. Symptoms may include pain, swelling,
bruising A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
, and an inability to walk on the injured leg. Complications may include an associated
high ankle sprain A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are desc ...
,
compartment syndrome Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the ...
, stiffness,
malunion A malunion is when a fractured bone does not heal properly. Some ways that it shows is by having the bone being twisted, shorter, or bent. Malunions can occur by having the bones improperly aligned when immobilized, having the cast taken off to ...
, and post-traumatic arthritis. Ankle fractures may result from excessive stress on the joint such as from rolling an ankle or from
blunt trauma Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...
. Types of ankle fractures include lateral
malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...
, medial malleolus, posterior malleolus, bimalleolar, and trimalleolar fractures. The Ottawa ankle rule can help determine the need for X-rays. Special X-ray views called stress views help determine whether an ankle fracture is unstable. Treatment depends on the fracture type. Ankle stability largely dictates non-operative vs. operative treatment. Non-operative treatment includes splinting or casting while operative treatment includes fixing the fracture with metal implants through an open reduction internal fixation ( ORIF). Significant recovery generally occurs within four months while completely recovery usually takes up to one year. Ankle fractures are common, occurring in over 1.8 per 1000 adults and 1 per 1000 children per year. They occur most commonly in young males and older females.


Functional anatomy

The
ankle The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joi ...
region refers to where the leg meets the foot (talocrural region). The ankle joint is a highly constrained, complex
hinge joint A hinge joint (ginglymus or ginglymoid) is a bone joint in which the articular surfaces are molded to each other in such a manner as to permit motion only in one plane. According to one classification system they are said to be uniaxial (having ...
composed of three bones: the tibia, the fibula, and the talus. The weight-bearing aspect of the tibia closest to the foot (known as the plafond) connects with the talus. This articulation (where two bones meet) is primarily responsible for plantarflexion (moving your foot down) and dorsiflexion (moving your foot up). Together the tibia and fibula form a bracket-shaped socket known as the mortise, into which the dome-shaped talus fits. The talus and the fibula are connected by a strong group of ligaments, which provide support for the lateral aspect of the ankle. These ligaments include the anterior talofibular ligament (ATFL) and the posterior talofibular ligament (PTFL). The calcaneofibular ligament (CFL), which connects the fibula to the calcaneus, or heel bone, also provides lateral support. The deltoid ligament provides support to the medial part of the ankle (closest to the midline). It prevents the foot from excessively everting, or turning outwards while also preventing the talus from externally rotating. The distal parts of the tibia and fibula are connected by a connective tissue network referred to as the syndesmosis, which consists of four ligaments and the interosseous membrane.


Signs and symptoms

Symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showi ...
s of an ankle
fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displ ...
can be similar to those of
ankle sprain A sprained ankle, also known as a twisted ankle or rolled ankle, is an injury where sprain occurs on one or more ligaments of the ankle. It is the most common injury to occur in ball sports, such as basketball, volleyball, football, and racquet ...
s (pain, swelling, limited range of motion), though typically they are often more severe by comparison. It is exceedingly rare for the ankle joint to dislocate in the presence of ligamentous injury alone. However, in the setting of an ankle fracture, the talus can become unstable and subluxate or dislocate. Patients may notice
ecchymosis A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...
("black and blue" coloration from bleeding under the skin), or there may be an abnormal position, alignment, gross instability, or lack of normal motion secondary to pain. In a displaced, fracture the skin is sometimes tented over a sharp edge of broken bone. The sharp fragments of broken bone sometimes tear the skin and form a laceration that communicates with the broken bone or joint space. This is known as an open fracture and has a high incidence of infection if not promptly treated.


Diagnosis


Physical Examination

Patients with ankle fractures may have variable findings on physical examination. Generally, the injured side should be compared to the non-injured side. The skin should be carefully examined, paying particular attention to any openings or breaks in the skin that could be due to an open fracture. It is important to evaluate the exact location of the pain, the range of motion of the ankle, and the condition of the nerves and blood vessels. It is also important to palpate the calf proximally (near the knee) because there may be an associated high fibula fracture (
Maisonneuve fracture The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of th ...
).


Imaging

Imaging for evaluation of ankle fractures can include x-rays, CT scans, and MRIs. Typically evaluation begins with x-rays, which can provide information about the mechanism of injury, severity of injury, and stability of fracture. The Ottawa ankle rules determine the necessity of obtaining x-rays in patients with acute ankle injuries. These guidelines were created to minimize the expense of unnecessary x-rays.


X-ray

''Views'' There are three x-ray views in a complete ankle series: anteroposterior (AP), lateral, and oblique (or "mortise view"). The mortise view is an AP x-ray taken with the ankle internally rotated 15-20 degrees since the foot is naturally externally rotated relative to the ankle. In addition to these views, a full-length view of the tibia and fibula may be necessary to evaluate for injuries to the proximal fibula associated with
Maisonneuve fracture The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of th ...
s. A specialized AP stress view of the ankle is performed when there is concern for an unstable ankle injury. There are two types of stress views: gravity and mechanical. In the gravity stress view, the patient lies in the lateral decubitus position with the ankle dangling over the edge of the table to mimic the mechanical stress view. ''Findings'' On X-rays, there can be a fracture of the
medial malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promi ...
, the
lateral malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...
, and/or of the anterior/posterior margin of the distal tibia. The posterior margin (known as the posterior malleolus) is much more frequently injured than the anterior aspect of the distal tibia. If both the lateral and medial malleoli are broken, this is called a bimalleolar fracture (some of them are called
Pott's fracture Pott's fracture, also known as Pott's syndrome I and Dupuytren fracture, is an archaic term loosely applied to a variety of bimalleolar ankle fractures. The injury is caused by a combined abduction external rotation from an eversion force. This ...
s). If the posterior malleolus is also fractured, this is called a trimalleolar fracture. File:TriplanefractureXa.png, A triplane fracture of the ankle as seen on plain X-ray File:TriplanefractureCT2.png, A triplane fracture of the ankle as seen on CT File:TriplanefractureCT1.png, A triplane fracture of the ankle as seen on CT


CT

CT scans may be indicated when there is concern for a highly
comminuted Comminuted may refer to: *Comminution, the process in which solid materials are reduced in size, by crushing, grinding and other processes *Bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there ...
fracture or a fracture involving the joint surface. This imaging may be used for surgical planning.


MRI

MRI is less commonly used to diagnose ankle fractures but may be used to show problems involving the soft tissues (ligaments and tendons) and
articular cartilage Hyaline cartilage is the glass-like (hyaline) and translucent cartilage found on many joint surfaces. It is also most commonly found in the ribs, nose, larynx, and trachea. Hyaline cartilage is pearl-gray in color, with a firm consistency and has ...
.


Classification

There are several classification schemes for ankle fractures. Out of the following, the Lauge-Hansen and Danis-Weber classification systems are most commonly used. * The Lauge-Hansen classification categorizes fractures based on the mechanism of the injury as it relates to the position of the foot and the deforming force (the most common type is supination-external rotation) * The Danis-Weber classification categorizes ankle fractures by the level of the fracture of the distal
fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity ...
(type A = below the syndesmotic ligament, type B = at its level, type C = above the ligament), with use in assessing injury to the syndesmosis and the
interosseous membrane An interosseous membrane is a thick dense fibrous sheet of connective tissue that spans the space between two bones, forming a type of syndesmosis joint. Interosseous membranes in the human body: * Interosseous membrane of forearm * Interosseous ...
''Other classification schemes:'' * The Herscovici classification categorizes
medial malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promi ...
fractures of the distal
tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it conn ...
based on level. * The Ruedi-Allgower classification categorizes pilon fractures of the distal
tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it conn ...
.


Pediatric fracture types

* Wagstaffe-Le Fort avulsion fracture¨, a vertical
fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displ ...
of the antero- medial part of the
distal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...
fibula The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity ...
with avulsion of the
anterior tibiofibular ligament The anterior ligament of the lateral malleolus (anterior tibiofibular ligament or anterior inferior ligament) is a flat, trapezoidal band of fibers, broader below than above, which extends obliquely downward and lateralward between the adjacent mar ...
. * Tillaux fracture, a Salter–Harris type III
fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displ ...
through the anterolateral aspect of the distal
tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it conn ...
l
epiphysis The epiphysis () is the rounded end of a long bone, at its joint with adjacent bone(s). Between the epiphysis and diaphysis (the long midsection of the long bone) lies the metaphysis, including the epiphyseal plate (growth plate). At the jo ...
. * Triplane fractures are a special type of fracture that involves the immature skeleton. It has a coronal plane in the metaphysis, an axial plane in the physis, and a sagittal plane in the epiphysis. File:Tillaux-Fraktur 11jw - Roe ap und seitlich - 001.png, Tillaux fracture


Treatment

The broad goals of treating ankle fractures are restoring the ankle joint to normal alignment, healing the fracture, and preventing arthritis. The stability of the ankle joint often dictates treatment. Certain fracture patterns are stable and are thus treated without surgery similarly to ankle sprains. Unstable fractures require surgery, most often an
open reduction and internal fixation Internal fixation is an operation in orthopedics that involves the surgical implementation of implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth century and was made applicable for routine treatment in the ...
(ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A
cast Cast may refer to: Music * Cast (band), an English alternative rock band * Cast (Mexican band), a progressive Mexican rock band * The Cast, a Scottish musical duo: Mairi Campbell and Dave Francis * ''Cast'', a 2012 album by Trespassers William ...
or splint will be required to immobilize the ankle following surgery. Stable ankle fractures with preserved joint alignment may be treated with non-operative measures (splinting, casting, and/or
walking boot A controlled ankle motion walking boot, or CAM boot, also sometimes called a below knee walking boot or moon boot, is an orthopedic device prescribed for the treatment and stabilization of severe sprains, fractures, and tendon or ligament tears i ...
).


Complications

General complications associated with surgical treatment include infection, bleeding, blood clots, wound healing problems, and damage to surrounding nerves and blood vessels. Specific complications associated with surgical treatment of ankle fractures include fracture healing in an abnormal position (
malunion A malunion is when a fractured bone does not heal properly. Some ways that it shows is by having the bone being twisted, shorter, or bent. Malunions can occur by having the bones improperly aligned when immobilized, having the cast taken off to ...
), post-traumatic arthritis, failed fracture healing after a prolonged period of time (
nonunion Nonunion is permanent failure of healing following a broken bone unless intervention (such as surgery) is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false j ...
), and decreased range of motion (post-operative stiffness). If post-operative x-rays are concerning for malunion, then patients may need an additional procedure to restore proper ankle anatomy. The ultimate goal is to prevent or delay the development of post-traumatic arthritis. Post-traumatic arthritis can initially be managed with conservative options like activity modification, non-steroidal anti-inflammatory medication (NSAIDs), specialized footwear, and cortisone injections. If patients still have pain and impaired ankle function after these measures, then other procedures such as ankle arthrodesis and ankle arthroplasty can be considered. Nonunion is rare following surgical fixation of ankle fractures but can be managed with bone grafts and stable internal fixation. Patients can also experience pain or discomfort from the metal hardware used to fix the fracture. As a result, some patients decide to have the hardware removed after the fracture has healed through an additional procedure.


Epidemiology

Several large studies have suggested that the incidence of ankle fractures has increased since the 1960s. The incidence is highest in elderly women over the age of 65, but importantly ankle fractures are not considered as fragility fractures. In terms of fracture type, isolated malleolar fractures are most common (two-thirds of fractures); bimalleolar fractures occur in roughly 25% of patients while trimalleolar fractures occur in 5-10%. Open fractures are rare, compromising 2% of all ankle fractures. In children, ankle fractures occur in about 1 per 1000 per year.


See also

*
Maisonneuve fracture The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of th ...
* Pilon fracture


References


External links


Medical information about Ankle Fractures
{{Fractures Bone fractures Wikipedia medicine articles ready to translate