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Ankle Fractures





What is an ankle fracture?
An ankle fracture is the same thing as a broken ankle.  The ankle joint is comprised of three bones: the tibia, fibula, and talus.  The tibia is the largest bone of these.  An ankle fracture is when either the tibia or fibula, or both is broken.  An ankle fracture can range from a simple break that does not limit walking, to one which requires complete non-weight bearing for 3 months.  If these fractures are displaced, surgery is almost always required for the best long term outcome.  The more breaks that are present, the worse the injury is.  Often times there are ligaments that are damaged as well.  Occasionally, cartilage withing the joint on any of the three ankle bones may be damages as well.


Etiology:
Fractures of the ankle joint can occur from "rolling," "twisting," "banging" of the ankle.  Tripping and falling, stepping in a hole/ditch, motor vehicle accidents, and other direct trauma can all cause these injuries. 

Ankle fractures are amongst the most common of all fractures, and the ankle joint is the most commonly injured weight-bearing joint.


This joint is subjected to approximately 1.5 times the body weight during normal walking, and up to 5.5 times the body weight during more strenuous activity.  The ankle joint has a relatively small surface area considering the amount of force it endures.  With displacement of these fractures 1mm, surface contact decreases by about 40%.  With 2mm of displacement, contact decreases by approximately 60%.   Abnormal/decreased contact leads to abnormal stresses in the joint and hence increased chance for arthritis.

Symptoms:
Usually pain presents immediately.  Most often swelling begins within several hours and it is very difficult to walk.  Bruising (black and blue) usually occurs at the area where the break is located.  This bruising can settle into the heel or toe area over time.  Less often it can travel up the leg from the area of the break.



Initial Treatment: (If you suspect you have an ankle fracture)

Following an ankle injury it is important to have the ankle evaluated by a foot and ankle surgeon for proper diagnosis and treatment. If you are unable to do so right away, go to the emergency room and then follow up with a foot and ankle surgeon as soon as possible for a more thorough assessment.

Until you are able to be examined by a doctor, the “R.I.C.E.” method should be followed. This involves: 

  • Rest. It is crucial to stay off the injured foot, since walking can cause further damage. Non-weightbearing with crutches or a walker is ideal. 
  • Ice. To reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
  • Compression. Wrap the ankle in an elastic bandage or wear a compression stocking to prevent further swelling.
  • Elevation. Keep the foot elevated to reduce the swelling. It should be even with or slightly above the hip level. 



Examples:

Non-displaced fracture:
The example below is a fracture that initially presented as a sprain.  The patient continued to have the same pain after three weeks.  The patient was able to walk with some discomfort, but the pain would not go away.  She noticed that there was more pain and stiffness in the back of her ankle once she woke up in the morning.  Also, the pain was more significant when she pointed her toes down.
 
                            

If you look closely at the image above and the enlarged part, you can see that there is a small irregularity in the bone - this is a fracture of the posterior part of the tibia (called the posterior malleolus).  This type of fracture is  non-displaced and the patient healed uneventfully in 6 weeks.  She was dispensed a night splint to keep her ankle at approximately 90 degrees while she slept.  This position allows the ligaments and bones to heal properly.  She was allowed to continue to walk but was limited to gentle walking only.




Minimally-displaced Fracture:
The example below is a patient who was dancing and sustained this injury.  The fracture seen in the xray below is a minimally-displaced fracture of the fibula.  This fracture was treated with a cast for immobilization and non-weight bearing with crutches for six weeks. For someone who was very active or athletic it might be recommended to surgically repair this fracture.  It would certainly heal with immobilization alone, but surgical intervention would allow early range of motions exercises and therefore provide a more rapid return to full activity.  Once stitches are removed (at about 2 weeks), the patient is placed in a removable CAM walker and is instructed/encouraged to actively move their ankle up and down as much as possible to prevent adhesions/stiffness, and prevent most loss of strength.  It is still recommended to maintain non-weight bearing for a full 6 weeks after the surgical repair (this is how long bones take to heal if primarilly repaired).

      





Displaced bimalleolar ankle fracture:
This fracture is called a bimalleolar fracture - meaning that both the fibular malleolus and tibial malleolus are broken.  This bimalleolar ankle fracture is dislocated and very unstable. Surgical intervention is the best method of treatment for this type of injury.  Internal fixation (plates and screws) allows early range of motion and thus helps to minimize the amount of muscular atrophy/wasting from lack of use.  Additionally, early range of motion helps prevent adhesions/stiffness that results from complete immobilization.  Also movement helps to reduce the associated swelling.  Surgery may be contraindicated in certain individuals depending upon their medical history.  If someone is non-ambulatory (does not walk), surgery may not be recommended.
 
 
          


For each of the above surgically repaired ankle fractures, a cast protector is a good option to allow you to keep your incisions and bandages dry while bathing.
For early range of motion after surgical repair, a CAM walker is usually utilized.

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