Ankle Fractures

Nkechi Nweke
Anatomy

The ankle is made up of two joints - the true ankle joint which allows dorsiflexion/plantarflexion, and the
subtalar joint which allows inversion/eversion.

The true ankle joint is a hinge synovial joint formed by articulation of 3 bones - distal tibia, distal fibula and
talus. The subtalar joint is beneath the true joint, with the talus sitting on the calcaneus.

Three malleoli are also contained within the ankle joint - the medial, lateral and posterior malleoli. Stability at
the ankle joint is provided by the syndesmosis between the distal tibia and fibula, deltoid ligaments and lateral
ligament complex. The medial ligament stabilizes the joint against eversion while the lateral ligament complex
stabilizes the joint against inversion.

Arterial supply is via branches from anterior tibial, posterior tibial and peroneal arteries. Venous drainage is
via corresponding veins. Innervation is supplied by branches of the superficial peroneal, deep peroneal and
tibial nerves.
Ankle fractures are the most common lower limb fractures found in any emergency department. About half of
the cases will present with unstable fractures which require surgical treatment. Chronic medical conditions
such as peripheral arterial disease, diabetes and metabolic bone disease may affect examination and
treatment.

Since ankle fractures and sprains may present with similar symptoms, a thorough history and examination is
needed to avoid misdiagnosis, unnecessary x rays and improper treatment.

Signs suggesting fracture include bony tenderness, ecchymosis, discolouration, swelling, gross deformity and
inability to bear weight on the injured foot.

Epidemiology

Males within the 10 to 19 age group have the highest incidence of ankle fractures but women are more
commonly affected across all other age groups. The highest incidence in women is between 75 to 84 age group.
The most common fracture type is the isolated uni malleolar fracture which accounts for 70% of all annual
ankle fractures. Bimalleolar and trimalleolar fractures account for 20% and 7% of cases respectively.
Etiology

Ankle fractures result from various forms of trauma such as tripping, impaction, crush injuries and twisting.
These injuries are commonly sustained in falls, sports injuries and road traffic accidents.
The degree of damage and bony comminution is directly proportional to the force of the trauma.

Pathophysiology
The ankle bones and ligaments form a complete ring around the ankle joint. Forceful trauma resulting in
disruption of the ring at one site results in a stable fracture; disruption at two or more sites result in unstable
fracture.
A full assessment of the ankle ring is required to avoid missing any ligamentous or bony injury.
Presentation

- Pain and tenderness at site of injury

- Discolouration and ecchymosis
- Deformity and swelling depending on extent of injury
- Unable to bear weight on injured foot/ankle

Physical Examination

- Inspect area for open wounds and skin discolouration

- Assess neurovascular status of affected side. Check for posterior tibial and dorsalis pedis artery
pulses. Check for arterial patency with handheld Doppler and capillary refill time. Compare findings
with unaffected side
- Palpate for focal tenderness especially along the malleoli
- Assess for active and passive ROM of the ankle joint
- Examine ipsilateral foot and knee especially for assessing proximal fibula and proximal 5th metatarsal
Investigations

- Plain x ray is the primary modality of investigation

- CT or MRI when findings by other modalities are equivocal

The Ottawa Ankle Rules is used to predict the necessity of radiographs for acute ankle injuries. This is to
protect patients from unnecessary radiation.

The rules state an x ray is required only if there is malleolar pain AND any one of :

- Inability to bear weight immediately for four steps

- Bony tenderness at the tips of lateral or medial malleoli
- Bony tenderness of the posterior tibia/fibula
Classification of Fractures

Different systems of classification exist:

1. Anatomical classification: is based on anatomical location of fractures:

- Isolated lateral malleolus fracture
- Isolated medial malleolus fracture
- Bimalleolar fracture
- Trimalleolar fracture

2. Danis-Weber classification: is based on distal fibula fracture line relative to the syndesmosis
- Weber type A: fracture line is below the syndesmosis
- Weber type B: fracture line is at the same level of the syndesmosis
- Weber type C: fracture line is above the syndesmosis

3. Lange-Hansen classification: is based on the foot position and direction of force responsible for the injury.
- Supination-adduction
- Supination-external rotation
- Pronation-external rotation
- Pronation-abduction
Differentials
- Ankle sprain /dislocation
- DVT
- Foot fracture
- Gout and pseudogout
- Arthritis
- Osteochondral lesion
- Tendon rupture
- Hindfoot fracture
- Syndesmotic injury

Treatment
Non operative treatment: is indicated in stable fractures, where patient is unfit or refusing surgery
and in poor soft tissue conditions.
Fracture reduction with application of a cast or moon boot is required for a minimum of 6 weeks.
Analgesia is given. Antibiotics and tetanus prophylaxis are required in open fractures.

Operative treatment: involves mainly ORIF with plates and screws.

Indications for surgery include unstable fractures, open fractures, displaced fractures and those with
neurovascular compromise.
Complications
Non Operative Management Operative Management

Ankle stiffness Infection

Delayed union / malunion Metal work failure

Ankle instability Nerves and vascular damage

DVT and PE Prominent screws

Skin ulceration from cast pressure Delayed union / non union

Delayed return to functionality Wound dehiscence and scarring

Prognosis

Ankle fracture prognosis can be improved with accurate and prompt diagnosis as well as appropriate treatment and
referral.
Isolated closed fractures have a better prognosis than complex open fractures with gross soft tissue involvement.
Aggressive physiotherapy decreases morbidity associated with ankle fractures.
Delayed care may increase complications especially where surgical treatment is warranted.
References

1. Ankle Fracture: Background, Pathophysiology, Epidemiology. (2020). EMedicine.

https://emedicine.medscape.com/article/824224-overview
2. Ankle Fractures: Review Article. (n.d.). Www.iomcworld.org.
https://www.iomcworld.org/open-access/ankle-fractures-review-article-46484.html
3. Kyriacou, H., Mostafa, A. M., Davies, B. M., & Khan, W. S. (2021). Principles and guidelines in the management of
ankle fractures in adults. Journal of Perioperative Practice, 175045892096902.
https://doi.org/10.1177/1750458920969029
4. Lampridis, V., Gougoulias, N., & Sakellariou, A. (2018). Stability in ankle fractures. EFORT Open Reviews, 3(5),
294–303. https://doi.org/10.1302/2058-5241.3.170057
5. Wire, J., & Slane, V. H. (2020). Ankle Fractures. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK542324/