Ankle Fracture
Ankle Fracture X-rays picture album Plain film radiographs of ankle fractures including acceptable radiographic parameters and post-reduction and post-operative x-rays.
Ankle Fracture picture album Several pictures illustrating ankle fractures and the Weber classification system. Ankle Fracture Surgery video 3D animation demonstrating open reduction-internal fixation of an ankle fracture. Ankle Fracture Anatomy picture album Several pictures demonstrating the anatomy of ankle fractures.
The ankle joint is formed where the fibula, tibia, and talus come together.  The lateral malleolus of the fibula and the medial malleolus of the tibia form a mortise in which the talus sits. The term “ankle fracture” typically refers to a fracture of the lateral malleolus, the medial malleolus, or both.  A broken ankle (fractured ankle = broken ankle) usually occurs as the result of twisting or “rolling” the ankle. “Ankle fracture” could also refer to a fracture of the talus, fracture of the calcaneus, or fracture of the tibial plafond. X-rays: AP, lateral, oblique (mortise view) of ankle CT scan: If there is need for more detailed, 3-dimensional evaluation of the fracture, a CT scan may be obtained. Need to evaluate the amount of intra-articular displacement Pre-operative planning in the case of a complex, comminuted fracture Classification: Open or closed Displaced or nondisplaced Location o Lateral malleolus o Medial malleolus o Bi-malleolar (medial and lateral malleoli are both fractured) o Tri-malleolar (medial, lateral, and posterior malleoli are fractured) Weber (based on location of lateral malleolus fracture) o A: fracture occurs below the level of the talar dome o B: fracture at level of talar dome (involving syndesmosis) B1 - just the lateral malleolus B2 - bimalleolar B3 - trimalleolar o C: fracture above the syndesmosis Lauge-Hansen (based on mechanism of injury) o Supination-adduction o Supination-external rotation o Pronation-external rotation o Pronation-abduction
Initial management: Emergent orthopedic surgery evaluation: o Open fractures o Fracture-dislocations (need reduction) o Compartment syndrome Urgent orthopedic surgery evaluation: o Unstable fracture patterns Unacceptable displacement/angulation of lateral malleolus Bi/tri-malleolar Widening of ankle mortise Immobilization o Stable fracture pattern Short-leg posterior splint CAM walker boot o Unstable fracture pattern Posterior splint with U-slab Bulky compression splint (Robert-Jones) Pack in ice Elevate Non-weightbearing Pain control Definitive treatment: Lateral malleolus o Nondisplaced or minimally displaced Acceptable alignment Mortise maintained - no widening No other bones involved Length and alignment maintained Short-leg cast May require splint to allow for swelling for 1 week following fracture 4-6 weeks Non-weightbearing except for exceptionally stable fractures (small avulsion fractures) Follow-up x-rays to ensure good alignment and healing Transition to walking cast or boot at 4-6 weeks as x-rays demonstrate healing After weight-bearing begins, physical therapy or home exercise program Range-of-motion Strengthening Proprioception o Displaced or unstable Unacceptable alignment Widening of the mortise Shortening Angulation Bi/tri-malleolar Surgical fixation Open reduction-internal fixation 4-6 weeks non-weightbearing after surgery in cast, splint, or boot Hardware does not typically need to be removed Physical therapy or home exercise program o Range of motion o Strengthening o Proprioception Medial malleolus o Nondisplaced or minimally displaced - casting o Displaced - percutaneous screw fixation or open reduction-internal fixation Bi/tri-malleolar - open reduction-internal fixation
Lateral malleolus is the distal most portion of the fibula Indications for surgical fixation o Displacement/angulation/shortening (< 3 mm displacement) o Associated fracture of the medial malleolus (bimalleolar fracture) o Injury to medial ligaments or syndesmosis that results in widening or instability of the ankle mortise X-rays may demonstrate widening of the ankle mortise Stress views may be obtained to evaluate for excessive motion of the talus within the mortise Treatment o Nondisplaced or minimally displaced If too swollen for cast, 1 week compression splint to allow for swelling Short leg cast 4-6 weeks - neutral position Physical therapy for range-of-motion, proprioception, strengthening o Displaced or unstable Reduce fracture - dislocations immediately Open reduction - internal fixation as soon as permitted by swelling
A bimalleolar ankle fracture is when both the lateral malleolus (fibula) and medial malleolus (tibia) are broken Bimalleolar fractures are unstable Treatment o Reduce fracture - dislocations immediately - use a compression splint to maintain good alignment o Open reduction - internal fixation as soon as permitted by swelling