Ankle fracture

The ankle region refers to where the leg meets the foot (talocrural region).[4] The ankle joint is a highly constrained, complex hinge joint composed of three bones: the tibia, the fibula, and the talus.[5][6] 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).[6] Together the tibia and fibula form a bracket-shaped socket known as the mortise, into which the dome-shaped talus fits.[7] 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).[8] 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.[8] 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.[8]

Symptoms of an ankle fracture can be similar to those of ankle sprains (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 ("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.[8]

Ankle anatomy

Surgically fixated bimalleolar ankle fracture

The broad goals of treating ankle fractures are restoring the ankle joint to normal alignment, healing the fracture, and preventing arthritis.[8] 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 (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A cast or splint will be required to immobilize the ankle following surgery.[11] Stable ankle fractures with preserved joint alignment may be treated with non-operative measures (splinting, casting, and/or walking boot).[11]

General complications associated with surgical treatment include infection, bleeding, blood clots, wound healing problems, and damage to surrounding nerves and blood vessels.[1] Specific complications associated with surgical treatment of ankle fractures include fracture healing in an abnormal position (malunion), post-traumatic arthritis, failed fracture healing after a prolonged period of time (nonunion), and decreased range of motion (post-operative stiffness).[8] 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.[8] Post-traumatic arthritis can initially be managed with conservative options like activity modification, non-steroidal anti-inflammatory medication (NSAIDs), specialized footwear, and cortisone injections.[15] 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.[16] Nonunion is rare following surgical fixation of ankle fractures but can be managed with bone grafts and stable internal fixation.[16] 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.[1]

Several large studies have suggested that the incidence of ankle fractures has increased since the 1960s.[17][18][19] The incidence is highest in elderly women over the age of 65, but importantly ankle fractures are not considered as fragility fractures.[19] 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%.[9] Open fractures are rare, compromising 2% of all ankle fractures.[20] In children, ankle fractures occur in about 1 per 1000 per year.[3]

• Maisonneuve fracture
• Pilon fracture

• Medical information about Ankle Fractures

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