What is Ankle Fractures?
Ankle fractures are common injuries that can happen from a simple twist for older, fragile individuals, or from a serious accident in younger people. The goal of treating these fractures is to restore stability and proper positioning to the ankle to prevent future arthritis due to injury.
Let’s talk about the anatomy of the ankle joint. It’s a hinge synovial joint that moves in one direction, allowing your foot to flex upward (dorsiflexion) and point downward (plantar flexion). The ankle joint is formed by the connection of three bones; the bottom part of your shinbone (tibia), the smaller lower leg bone (fibula), and the bone on top of your foot (talus bone). The ends of both your tibia and fibula form a sort of socket, known as the ankle mortice, which holds the talus bone.
There are three protruding parts of the bones called malleoli that you feel in your ankles; the outer part (lateral malleolus at the end of the fibula), the inner part (medial malleolus at the lower end of the tibia), and one behind the ankle (posterior malleolus).
The stability of the ankle joint mainly comes from the ankle mortice, which holds the talus bone, the strong fibrous joint known as the ankle syndesmosis connecting the lower ends of the tibia and fibula, and the ligaments and muscles that surround the ankle joint. The ankle syndesmosis is formed by three main parts that connect the tibia and fibula. The deltoid ligament starts from the inner ankle part and attaches to several bones, providing stability and preventing excessive outward tilt of the foot. The ankle also has a complex set of three ligaments connected to the outer ankle part and attach to bones that resist the excessive inward tilt of the foot.
The ankle joint is supplied by nerves from the tibial nerve and peroneal nerves, and the blood to the ankle joint is supplied by branches from arteries in the lower leg.
What Causes Ankle Fractures?
Ankle fractures can occur due to different types of trauma like twisting, impact, and crush injuries. Twisting forces that harm the ankle often happen when you fall, trip, or engage in sports. Impact injuries could be a result of falling from a height with the lower end of the shin and calf bones (tibia and fibula) hitting hard against the ankle bone (talus).
Crush injuries to the ankle might occur due to a car accident or having the ankle caught under a heavy object. The extent of damage to the bones and surrounding soft tissues is directly tied to the force of the trauma.
Risk Factors and Frequency for Ankle Fractures
Ankle fractures are a common injury, with approximately 187 out of every 100,000 adults experiencing one each year. Women are most likely to sustain an ankle fracture between the ages 75 and 84, while for men, this risk is highest between the ages of 15 and 24.
- The most common type of ankle fracture is the isolated uni malleolar fracture, representing 70% of all reported cases each year.
- 20% of all ankle fractures are classified as bimalleolar fractures.
- Trimalleolar fractures make up about 7% of all ankle fractures.
- Open ankle fractures, which often require immediate medical attention, account for about 2% of all ankle fractures.
Signs and Symptoms of Ankle Fractures
When assessing a medical condition, it’s crucial to understand the patient’s complete background. This involves a thorough understanding of their:
- Medical history: Any existing conditions like diabetes, vascular diseases, obesity, kidney diseases, and inflammatory joint diseases may impact the outcome of ankle fractures. For example, conditions like unchecked diabetes or vascular issues may hamper the healing process of fractures. All such conditions should be managed effectively before undergoing surgery.
- Social background: The patient’s typical way of life and their objectives for the future play a significant role in their recovery. Things like their activity level before the injury, their living conditions, and their day-to-day activities are all important. Habits like smoking and heavy drinking can delay the healing of wounds or fractures.
- Injury history: Understanding exactly how the injury occurred can shed light on its severity. For instance, a high-energy injury may signal serious issues like a compartment syndrome, which is a painful condition caused when pressure within the muscles builds to dangerous levels. The positioning of the ankle during the incident and the direction of the force can anticipate the type of fracture, as described in the Lauge-Hansen classification system.
Finally, it is essential to evaluate the risk for Venous thromboembolism (VTE), a condition where blood clots form due to an injury. Risk factors include smoking, past instances of VTE, high body mass index, use of hormonal therapy, and oral contraceptive pills. Patients with high risk for VTE should be given appropriate preventive treatment.
Testing for Ankle Fractures
When you’re taken to the hospital after a trauma or accident, the medical team follows a specific process known as an “Adult Trauma Life Support Primary and Secondary Survey.” This process helps them quickly identify any life-threatening injuries you may have. It’s done in an orderly manner, from A to E:
* A: Airway management and keeping your neck stable.
* B: Checking your breathing.
* C: Checking your blood circulation and stopping any heavy bleeding.
* D: Assessing any disabilities or neurologic status.
* E: Thoroughly checking your whole body for injuries.
If you hurt your ankle, a special assessment (neurovascular assessment) will be done. This checks the color and temperature of your foot, which helps the medical team understand if the blood flow to the foot is normal. They also check for the pulse and sensation in your foot. If your doctors are worried about your foot based on these findings, they will try to adjust your ankle back into position to restore normal blood flow.
They also look at the skin around the injured ankle to monitor any threats or damage. The condition of your skin and how much swelling there is can affect your treatment plan.
They also check the fibula bone near your knee to make sure there are no other injuries.
A set of rules called the “Ottawa Ankle Rules” help doctors determine if they need to do an x-ray of your ankle. They use this if you have pain and tenderness around your ankle or an inability to walk properly.
Different imaging techniques are used to aid in the diagnosis.
1. Plain Radiographs or X-rays: These are usually the first step to look at the ankle injury. They take pictures from different angles which provide different views of the ankle.
2. Computed Tomography (CT scan): If your ankle fracture is complex, a CT scan may be used. This helps the doctors assess the fracture in more detail and plan surgery if needed.
3. Magnetic Resonance Imaging (MRI) Scan: An MRI scan is used to examine soft tissues in your ankle like ligaments and assess any damage. For example, it can show if you have a sprained ligament or a stress fracture.
Treatment Options for Ankle Fractures
The treatment of ankle fractures aims to restore and stabilize the ankle joint, and this can be done either through non-surgical or surgical methods. Non-surgical methods are usually chosen when the ankle fracture is stable, such as when the bones have not been displaced. This might be the case if you only have a fracture in one area of the ankle and the ankle bones are still aligned properly. Medical professionals may also opt for non-surgical treatment if you are not fit enough for surgery, do not want to undergo surgery, or if the soft tissues around your ankle are in poor condition.
Non-surgical treatment can include wearing a cast that goes up to your knee, using a walking boot, receiving pain relief medication, and if the fracture is unstable, getting the bones realigned and then being put in a close contact cast. This last method can be a good choice for patients over 60 years old or those who are unfit for surgery.
If the fracture is unstable, meaning the bones have been displaced, surgery may be necessary. An ankle fracture is termed as unstable when the bones that form the ankle joint are no longer lined up. This can occur if you have fractures in multiple areas of the ankle, a certain type of high-energy impact fracture known as a Pilon fracture, or a specific type of spiral fracture called a Maisonneuve fracture. Open reduction and internal fixation (ORIF) is the common surgical procedure used for ankle fractures. This process involves repositioning the bones in their correct alignment and holding them in place with hardware like plates and screws. The timing of the surgery can vary – it might occur within 24 hours of injury or a few days after, depending on factors like the amount of swelling in the ankle and the condition of the surrounding soft tissues.
Sometimes, a type of temporary external brace may be used to stabilize the ankle if the alignment of the ankle joint cannot be maintained due to severe swelling or because the fracture is open (the bone has broken through the skin). This puts the ankle in a safe position while the soft tissues heal. Later, the complete surgical fixation can be done when the soft tissues have healed and can be safely closed. It’s important to note that the site of the surgical approach should be considered while applying the external braces to avoid interfering with the future surgery.
In any case, the treatment plan for an ankle fracture is based on factors like your age, the type of fracture, and your general health condition. The goal is to stabilize the ankle and get you back to your daily activities as safely and quickly as possible.
What else can Ankle Fractures be?
If you’ve hurt your ankle, it might be a broken bone, but it could also be a few other things. The two common conditions are a Deltoid Ligament Sprain or a Lateral Collateral Complex Sprain. They’re a bit similar in symptoms as you would typically feel tenderness and swelling in the inner part of your ankle, and x-rays might show a shift in your talar bone. An MRI scan could be useful to diagnose these conditions too.
Another condition to consider would be a Tendon Achilles Rupture. Here, you might have experienced a sharp pain or a snap feeling in the back of your affected ankle. The doctor will examine you, and they might find a gap where the Achilles tendon should be. A test called the Simmonds test could be performed. In this, the doctor will squeeze your calf muscles, and if your foot doesn’t move, that’s a positive sign of a Tendon Achilles Rupture. While x-rays typically don’t show anything here, an ultrasound scan can be helpful in assessing the rupture and the length of the gap in the tendon.
What to expect with Ankle Fractures
For people with stable breaks that don’t need surgery, recovery prospects are excellent. They can gradually start to use the injured area and return to their normal activities as early as 6 to 8 weeks after the injury. However, for those with unstable breaks that have undergone Open Reduction and Internal Fixation (ORIF, a surgical procedure to fix a severe bone fracture), while they could be bearing weight as soon as 6 to 8 weeks, achieving full functional recovery might take longer.
It’s important to note that even with proper alignment and fixation of the ankle fracture, roughly 14% of people will experience post-traumatic arthritis in the ankle joint. This could be due to a chondral injury, which is an injury to the smooth surface on the end of bones where they connect to form joints.
Possible Complications When Diagnosed with Ankle Fractures
Complications can happen after an ankle fracture, no matter if the treatment was non-surgical or surgical.
Non-Surgical Treatment Complications might be:
- Stiffness in the ankle
- Deep vein thrombosis and lung clot
- The ankle moving out of place again and needing re-adjustment
- Skin sores because of the pressure of the cast
- Delayed healing of the fracture
- Non-healing fractures
- Fracture healing in an abnormal position
- Long-term instability of the ankle
- Slow resumption of normal activities
- Arthritis changes in the ankle
Surgical Treatment Complications might be:
- Infection
- Painful scarring
- The surgical wound coming open
- Failure of metal implants like plates or screws
- Inappropriately placed metal implants
- Protruding screws
- Non-healing fractures
- Delayed healing of the fracture
- Damage to nerves
- Damage to blood vessels
People with diabetes can have a rare complication after an ankle fracture known as Charcot arthropathy or neuropathic arthropathy. This means that the ankle joint breaks down progressively, resulting in destructive changes in the bone structure leading to deformity. Long-term issues might include skin ulcers, infections, and the ankle might even need to be amputated.
Preventing Ankle Fractures
In people who have broken their ankle, understanding their injury and the healing process is really important. For patients with stable fractures (ones that won’t move out of place) that do not need surgery, they need to know when they should come back to the doctor for a check-up. They should also understand how their body will normally heal, and when they should be concerned if their healing isn’t progressing as expected.
For patients who do need surgery for their ankle fractures, they should understand the significance of physical therapy and the goals for putting weight on their ankle before they leave the hospital. It is crucial to let them know about any warning signs, or “red flags,” that suggest their ankle isn’t healing properly or quickly enough.