Ankle fracture

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Ankle fracture
Other namesBroken ankle [1]
Bimalleolar fracture legend.jpg
Fracture of both sides of the ankle with dislocation as seen on anteroposterior X-ray. (1) fibula, (2) tibia, (arrow) medial malleolus, (arrowhead) lateral malleolus
Specialty Orthopedics
Symptoms Pain, swelling, bruising, inability to walk [1]
Complications High ankle sprain, compartment syndrome, decreased range of motion, malunion [1] [2]
Usual onsetYoung males, older females [2]
TypesLateral malleolus, medial malleolus, posterior malleolus, bimalleolar, trimalleolar [1]
CausesRolling the ankle, blunt trauma [2]
Diagnostic method X-rays based on the Ottawa ankle rule [2]
Differential diagnosis Rheumatoid arthritis, gout, septic arthritis, Achilles tendon rupture [2]
Treatment Splinting, casting, surgery [1]
Frequency~1 per 1000/year [2]

An ankle fracture is a break of one or more of the bones that make up the ankle joint. [1] Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. [1] Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis. [1] [2]

Contents

Ankle fractures may result from excessive stress on the joint such as from rolling an ankle or from blunt trauma. [1] [2] Types of ankle fractures include lateral malleolus, medial malleolus, posterior malleolus, bimalleolar, and trimalleolar fractures. [1] The Ottawa ankle rule can help determine the need for X-rays. [2] Special X-ray views called stress views help determine whether an ankle fracture is unstable.

Treatment depends on the fracture type. Ankle stability largely dictates non-operative vs. operative treatment. Non-operative treatment includes splinting or casting while operative treatment includes fixing the fracture with metal implants through an open reduction internal fixation (ORIF). [1] Significant recovery generally occurs within four months while completely recovery usually takes up to one year. [1]

Ankle fractures are common, occurring in over 1.8 per 1000 adults and 1 per 1000 children per year. [2] [3] In North America this figure increases to more than 14 in ever 10,000 patients admitted to the Emergency Room. [4] They occur most commonly in young males and older females. [2]

Functional anatomy

The ankle region refers to where the leg meets the foot (talocrural region). [5] The ankle joint is a highly constrained, complex hinge joint composed of three bones: the tibia, the fibula, and the talus. [6] [7] 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). [7] Together the tibia and fibula form a bracket-shaped socket known as the mortise, into which the dome-shaped talus fits. [8] 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). [9] 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. [9] 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. [9]

Signs and symptoms

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. [9]

Ankle anatomy Ankle en.svg
Ankle anatomy

Diagnosis

Physical Examination

Patients with ankle fractures may have variable findings on physical examination. Generally, the injured side should be compared to the non-injured side. The skin should be carefully examined, paying particular attention to any openings or breaks in the skin that could be due to an open fracture. [10] It is important to evaluate the exact location of the pain, the range of motion of the ankle, and the condition of the nerves and blood vessels. It is also important to palpate the calf proximally (near the knee) because there may be an associated high fibula fracture [ citation needed ](Maisonneuve fracture).

Imaging

Imaging for evaluation of ankle fractures can include x-rays, CT scans, and MRIs. Typically evaluation begins with x-rays, which can provide information about the mechanism of injury, severity of injury, and stability of fracture. The Ottawa ankle rules determine the necessity of obtaining x-rays in patients with acute ankle injuries. These guidelines were created to minimize the expense of unnecessary x-rays. [9]

X-ray

Views

There are three x-ray views in a complete ankle series: anteroposterior (AP), lateral, and oblique (or "mortise view"). The mortise view is an AP x-ray taken with the ankle internally rotated 15-20 degrees since the foot is naturally externally rotated relative to the ankle. [9] In addition to these views, a full-length view of the tibia and fibula may be necessary to evaluate for injuries to the proximal fibula associated with Maisonneuve fractures.[ citation needed ]

A specialized AP stress view of the ankle is performed when there is concern for an unstable ankle injury. There are two types of stress views: gravity and mechanical. [11] In the gravity stress view, the patient lies in the lateral decubitus position with the ankle dangling over the edge of the table to mimic the mechanical stress view.[ citation needed ]

Findings

On X-rays, there can be a fracture of the medial malleolus, the lateral malleolus, and/or of the anterior/posterior margin of the distal tibia. The posterior margin (known as the posterior malleolus) is much more frequently injured than the anterior aspect of the distal tibia. If both the lateral and medial malleoli are broken, this is called a bimalleolar fracture (some of them are called Pott's fractures). If the posterior malleolus is also fractured, this is called a trimalleolar fracture. [ citation needed ]

AP manual stress view showing a deltoid ligament tear Stress-view-of-ankle-with-deltoid-ligament-tear.jpg
AP manual stress view showing a deltoid ligament tear

CT

CT scans may be indicated when there is concern for a highly comminuted fracture or a fracture involving the joint surface. [10] This imaging may be used for surgical planning.

MRI

MRI is less commonly used to diagnose ankle fractures but may be used to show problems involving the soft tissues (ligaments and tendons) and articular cartilage. [12]

Classification

Danis-Weber classification (type A, B and C) Weber Classification - latin.svg
Danis-Weber classification (type A, B and C)

There are several classification schemes for ankle fractures. Out of the following, the Lauge-Hansen and Danis-Weber classification systems are most commonly used. [9]

Other classification schemes:

Pediatric fracture types

Treatment

Surgically fixated bimalleolar ankle fracture Bimall3.png
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. [9] 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. [12] Stable ankle fractures with preserved joint alignment may be treated with non-operative measures (splinting, casting, and/or walking boot). [12]

Complications

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). [9] 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. [9] Post-traumatic arthritis can initially be managed with conservative options like activity modification, non-steroidal anti-inflammatory medication (NSAIDs), specialized footwear, and cortisone injections. [16] 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. [17] Nonunion is rare following surgical fixation of ankle fractures but can be managed with bone grafts and stable internal fixation. [17] 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]

Epidemiology

Several large studies have suggested that the incidence of ankle fractures has increased since the 1960s. [18] [19] [20] The incidence is highest in elderly women over the age of 65, but importantly ankle fractures are not considered as fragility fractures. [20] 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%. [10] Open fractures are rare, compromising 2% of all ankle fractures. [21] In children, ankle fractures occur in about 1 per 1000 per year. [3]

See also

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The leg is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or buttock region. The major bones of the leg are the femur, tibia, and adjacent fibula.

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

<span class="mw-page-title-main">Tibia</span> Leg bone in vertebrates

The tibia, also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates ; it connects the knee with the ankle. The tibia is found on the medial side of the leg next to the fibula and closer to the median plane. The tibia is connected to the fibula by the interosseous membrane of leg, forming a type of fibrous joint called a syndesmosis with very little movement. The tibia is named for the flute tibia. It is the second largest bone in the human body, after the femur. The leg bones are the strongest long bones as they support the rest of the body.

<span class="mw-page-title-main">Fibula</span> Leg bone in vertebrates

The fibula or calf bone is a leg bone on the lateral side of the tibia, to which it is connected above and below. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. Its upper extremity is small, placed toward the back of the head of the tibia, below the knee joint and excluded from the formation of this joint. Its lower extremity inclines a little forward, so as to be on a plane anterior to that of the upper end; it projects below the tibia and forms the lateral part of the ankle joint.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, the talocrural region or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

Pott's fracture, also known as Pott's syndrome I and Dupuytren fracture, is an archaic term loosely applied to a variety of bimalleolar ankle fractures. The injury is caused by a combined abduction external rotation from an eversion force. This action strains the sturdy medial (deltoid) ligament of the ankle, often tearing off the medial malleolus due to its strong attachment. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus. A fractured fibula in addition to detaching the medial malleolus will tear the tibiofibular syndesmosis. The combined fracture of the medial malleolus, lateral malleolus, and the posterior margin of the distal end of the tibia is known as a "trimalleolar fracture".

<span class="mw-page-title-main">Maisonneuve fracture</span> Medical condition

The Maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. There is an associated fracture of the medial malleolus or rupture of the deep deltoid ligament of the ankle. This type of injury can be difficult to detect.

<span class="mw-page-title-main">Tibialis posterior muscle</span> Muscle in the most central of all the leg muscles

The tibialis posterior muscle is the most central of all the leg muscles, and is located in the deep posterior compartment of the leg. It is the key stabilizing muscle of the lower leg.

<span class="mw-page-title-main">Talus bone</span> One of the foot bones that forms the tarsus

The talus, talus bone, astragalus, or ankle bone is one of the group of foot bones known as the tarsus. The tarsus forms the lower part of the ankle joint. It transmits the entire weight of the body from the lower legs to the foot.

<span class="mw-page-title-main">Ottawa ankle rules</span> Medical guidelines

In medicine, the Ottawa ankle rules are a set of guidelines for clinicians to help decide if a patient with foot or ankle pain should be offered X-rays to diagnose a possible bone fracture. Before the introduction of the rules most patients with ankle injuries would have been imaged. However the vast majority of patients with unclear ankle injuries do not have bone fractures. As a result, many unnecessary X-rays were taken, which was costly, time-consuming and a slight health risk due to radiation exposure.

<span class="mw-page-title-main">Superior tibiofibular joint</span> Joint in the knee

The superior tibiofibular articulation is an arthrodial joint between the lateral condyle of tibia and the head of the fibula.

<span class="mw-page-title-main">Lateral collateral ligament of ankle joint</span> Ligaments of the ankle

The lateral collateral ligament of ankle joint are ligaments of the ankle which attach to the fibula.

<span class="mw-page-title-main">Malleolus</span> Ankle bone protrusion

A malleolus is the bony prominence on each side of the human ankle.

<span class="mw-page-title-main">Trimalleolar fracture</span> Medical condition

A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. The trauma is sometimes accompanied by ligament damage and dislocation.

A high ankle sprain, also known as a syndesmotic ankle sprain (SAS), is a sprain of the syndesmotic ligaments that connect the tibia and fibula in the lower leg, thereby creating a mortise and tenon joint for the ankle. High ankle sprains are described as high because they are located above the ankle. They comprise approximately 15% of all ankle sprains. Unlike the common lateral ankle sprains, when ligaments around the ankle are injured through an inward twisting, high ankle sprains are caused when the lower leg and foot externally rotates.

The Bosworth fracture is a rare fracture of the distal fibula with an associated fixed posterior dislocation of the proximal fibular fragment which becomes trapped behind the posterior tibial tubercle. The injury is caused by severe external rotation of the ankle. The ankle remains externally rotated after the injury, making interpretation of X-rays difficult which can lead to misdiagnosis and incorrect treatment. The injury is most commonly treated by open reduction internal fixation as closed reduction is made difficult by the entrapment of the fibula behind the tibia.

<span class="mw-page-title-main">Danis–Weber classification</span> Method to classify an ankle fracture

The Danis–Weber classification is a method of describing ankle fractures. It has three categories:

<span class="mw-page-title-main">Crus fracture</span>

A crus fracture is a fracture of the lower legs bones meaning either or both of the tibia and fibula.

<span class="mw-page-title-main">Tibial plateau fracture</span> Medical condition

A tibial plateau fracture is a break of the upper part of the tibia (shinbone) that involves the knee joint. This could involve the medial, lateral, central, or bicondylar. Symptoms include pain, swelling, and a decreased ability to move the knee. People are generally unable to walk. Complication may include injury to the artery or nerve, arthritis, and compartment syndrome.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 "Ankle Fractures (Broken Ankle) - OrthoInfo - AAOS". www.orthoinfo.org. Retrieved 20 June 2019.
  2. 1 2 3 4 5 6 7 8 9 10 11 Wire J, Slane VH (9 May 2019). "Ankle Fractures". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   31194464.
  3. 1 2 Yeung DE, Jia X, Miller CA, Barker SL (April 2016). "Interventions for treating ankle fractures in children". The Cochrane Database of Systematic Reviews. 2016 (4): CD010836. doi:10.1002/14651858.CD010836.pub2. PMC   7111433 . PMID   27033333.
  4. ↑ Ptak NA, Rigby RB (2024). "Subluxation of the posterior tibial tendon into the tibiofibular syndesmosis secondary to high-level ankle fracture or dislocation: Surgical reduction technique guide and case study". Foot & Ankle Surgery: Techniques, Reports & Cases. 4 (1): 100357. doi: 10.1016/j.fastrc.2023.100357 . ISSN   2667-3967.
  5. ↑ Moore KL. Clinically oriented anatomy. ISBN   978-1-9751-5086-0. OCLC   1112382966.
  6. ↑ Brockett CL, Chapman GJ (June 2016). "Biomechanics of the ankle". Orthopaedics and Trauma. 30 (3): 232–238. doi:10.1016/j.mporth.2016.04.015. PMC   4994968 . PMID   27594929.
  7. 1 2 Thompson CJ (2015). Netter's concise orthopaedic anatomy, updated edition. Elsevier. ISBN   978-0-323-42970-2. OCLC   946457800.
  8. ↑ "The Ankle Joint - Articulations - Movements - TeachMeAnatomy" . Retrieved 2021-03-09.
  9. 1 2 3 4 5 6 7 8 9 10 Coughlin MJ, Saltzman CL, Mann RA (2014). Mann's surgery of the foot and ankle. Saunders/Elsevier. ISBN   978-0-323-07242-7. OCLC   883562707.
  10. 1 2 3 Koval KJ (28 March 2012). Handbook of fractures. Lippincott Williams & Wilkins. ISBN   978-1-4511-4837-4. OCLC   1233314470.
  11. ↑ Murphy A. "Ankle (stress view) | Radiology Reference Article | Radiopaedia.org". Radiopaedia. Retrieved 2021-03-23.
  12. 1 2 3 Carr JB (2009), "Malleolar Fractures and Soft Tissue Injuries of the Ankle", Skeletal Trauma, Elsevier, pp. 2515–2584, doi:10.1016/b978-1-4160-2220-6.10060-x, ISBN   978-1-4160-2220-6 , retrieved 2021-03-24
  13. ↑ Hunter TB, Peltier LF, Lund PJ (2000). "Radiologic history exhibit. Musculoskeletal eponyms: who are those guys?" (PDF). Radiographics. 20 (3): 819–36. doi:10.1148/radiographics.20.3.g00ma20819. PMID   10835130.
  14. ↑ "Wheeless Online" . Retrieved 30 October 2014.
  15. ↑ Hirsch M, et al. Understanding triplane distal tibia fractures. http://dx.doi.org/10.1016/j.rchira.2016.09.002
  16. ↑ Ewalefo SO, Dombrowski M, Hirase T, Rocha JL, Weaver M, Kline A, et al. (December 2018). "Management of Posttraumatic Ankle Arthritis: Literature Review". Current Reviews in Musculoskeletal Medicine. 11 (4): 546–557. doi:10.1007/s12178-018-9525-9. PMC   6220012 . PMID   30327933.
  17. 1 2 Carr JB (2009). "Malleolar Fractures and Soft Tissue Injuries of the Ankle". Skeletal Trauma. Elsevier. pp. 2515–2584. doi:10.1016/b978-1-4160-2220-6.10060-x. ISBN   978-1-4160-2220-6.
  18. ↑ Kannus P, Parkkari J, Niemi S, Palvanen M (December 1996). "Epidemiology of osteoporotic ankle fractures in elderly persons in Finland". Annals of Internal Medicine. 125 (12): 975–8. doi:10.7326/0003-4819-125-12-199612150-00007. PMID   8967708. S2CID   20553362.
  19. ↑ Daly PJ, Fitzgerald RH, Melton LJ, Ilstrup DM (October 1987). "Epidemiology of ankle fractures in Rochester, Minnesota". Acta Orthopaedica Scandinavica. 58 (5): 539–44. doi:10.3109/17453678709146395. PMID   3425285.
  20. 1 2 Bengnér U, Johnell O, Redlund-Johnell I (February 1986). "Epidemiology of ankle fracture 1950 and 1980. Increasing incidence in elderly women". Acta Orthopaedica Scandinavica. 57 (1): 35–7. doi:10.3109/17453678608993211. PMID   3083643.
  21. ↑ Court-Brown CM, McBirnie J, Wilson G (February 1998). "Adult ankle fractures--an increasing problem?". Acta Orthopaedica Scandinavica. 69 (1): 43–7. doi:10.3109/17453679809002355. PMID   9524517.
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