The Broken Ankle
What is the anatomy of the ankle?
The ankle joint is a hinge joint that consists of parts of three bones: the tibia, the fibula, and the talus. The bottom (distal) end of the fibula forms the lateral malleolus which is the bump on the outside of the ankle. The bottom (distal) end of the tibia (the “shin bone”) forms the medial malleolus which is the bump on the inside of the ankle, the posterior malleolus on the back of the ankle, and the plafond, or “ceiling” of the joint. The medial and lateral malleoli can be felt on the patient’s ankle as the bone bumps just under the skin on the inside and outside of the ankle. The talus is the bone on the bottom that hinges back and forth inside the “mortise” formed by the medial and lateral malleoli. There are ligaments that attach the talus to the malleoli and allow the talus to hinge. The deltoid ligament is on the inside, or medial side, of the ankle and attaches the medial malleolus to the talus. The ligaments on the outside, or lateral side, of the ankle attach to the lateral malleolus and are divided into three parts: the anterior talofibular ligament (ATFL), the calcaneofibular ligament, and the posterior talobifular ligament. The anterior talofibular ligament (ATFL) is the ligament that is most commonly injured in a typical sprained ankle. The tibia and fibula are held together by the syndesmotic ligaments. These are the ligaments that are injured in a “high ankle sprain.” Syndesmotic injuries (high ankle sprains) sometimes accompany an broken ankle.
The medial and lateral maleolli, with their ligaments, form a stable “mortise” that contains the talus and allows it to hinge, but keeps it stable and does not allow it to slide. An ankle fracture can compromise this stability and allow the talus to slide out of position.
What is the definition of a broken ankle?
The three bones that make up the ankle joint can be fractured, or broken, in many different ways, but not all of these breaks are referred to as an “ankle fracture.” A broken ankle or ankle fracture is when one or more of the malleoli are broken or cracked. An ankle fracture can vary from mild to severe. Occasionally, the ankle joint may be dislocated, or completely out of socket, in association with a broken ankle. This is a more severe injury. There are several ways to classify an ankle fracture.
One way to classify them is by the number of malleoli that are fractured:
- In a unimalleolar fracture, just one malleolus is fractured (usually the lateral one.) These may or may not benefit from surgery.
- In a bimalleolar fracture, two of the malleoli are fractured (usually the medial and lateral ones). These usually benefit from surgery.
- In a tramalleolar fracture, all three of the malleoli are fractured. These usually benefit from surgery.
Another way to classify a broken ankle is by where the lateral malleolus is fractured. This is the “Weber/AO” system:
- Type A is below the level of the joint. These usually do not need surgery.
- Type B is at the level of the joint. These may or may not benefit from surgery.
- Type C is above the level of the joint. These usually benefit from surgery.
Yet another way to classify a broken ankle is by the Lauge-Hansen system. This system is a bit more complex and divides ankle fractures into four groups based on mechanism of injury with a total of thirteen subgroups.
What are the risk factors for a broken ankle?
Risk factors for a broken ankle include contact sports, jumping and twisting sports, increased body mass, and age. Ankle fractures have been sustained by many elite athletes, including Roydell Williams of the Tennessee Titans, David Clarkson of the New Jersey Devils, and Jeremy Shockey of the New Orleans Saints.
What are the causes of injury?
A broken ankle can result from either indirect or direct contact mechanisms. Indirect injuries often occur without contact and are rotational in nature. These can be sustained in virtually every sport. However, significant direct trauma in contact sports such as football, rugby, and hockey can result in ankle fractures and are often higher energy injuries.
How is the diagnosis of a broken ankle made?
The diagnosis of a broken ankle is made with x-rays. However, when athletes injure their ankles, it is usually a sprained ankle. Not everyone with a sprained ankle needs to go get x-rays. The Ottawa ankle guidelines help to decide when to get x-rays. The guidelines state that x-rays are needed if there is pain near the malleoli and one or more of the following are present:
- Age 55 years or older
- The patient can’t put weight on the ankle
- Bone tenderness at the posterior edge or tip of either malleolus
MRI’s and CT’s are not usually needed for broken ankle diagnosis.
When is treatment without surgery appropriate?
Treatment of a broken ankle without surgery is appropriate if it is an isolated fracture of the lateral malleolus at or below the level of the joint with no medial widening that would indicate a ruptured deltoid ligament. The following conditions must be met:
- The talus is centered in the mortise
- There is not a medial malleolus fracture
- The space between the medial malleolus and the talus is not widened on x-rays
Your physician might consider more x-rays with your ankle on its side or “stress x-rays” if there is a question of medial widening.
Nonoperative treatment may consist of a short leg cast or a brace for 4-6 weeks. Weight bearing may be allowed when it no longer hurts to put weight on it. After 4-6 weeks, range of motion and strengthening exercises are used to re-establish strength and flexibility. Sports can usually be resumed at 3 months if strength, range of motion, and agility are re-established.
Is there a role for injections in ankle fractures?
There is not usually a role for injections in ankle fractures.
When is surgery indicated?
Surgery is usually indicated if:
- It is a bimalleolar or trimalleolar fracture with loss of stability of the “mortise”
- There is an associated ankle dislocation
- There is medial widening on the x-ray (increased space between the medial malleolus and talus)
What does surgery consist of?
Occasionally the ankle has to be “set” or “reduced” right away after the injury to relocate the ankle or to get the bones lined up better while waiting for surgery. Once the decision for surgery has been made, it can be performed right away if the swelling is not too severe. However, more commonly the ankle is splinted, the patient may go home on crutches, and the surgery may be performed several days or a week later allowing for scheduling and also allowing the swelling to go down. During this time it is very important to keep the ankle elevated above the level of the heart to decrease swelling so as to minimize the chances of wound healing problems.
Usually it is an outpatient surgery and the patient goes home the same day of the surgery. The surgery is dependent on what type of ankle fracture it is, but typically one or two incisions are made, the bones are placed back in the appropriate positions, and then plates and screws are used to hold them in place. Usually the hardware is left in forever, but occasionally it causes some irritation, in which case it may be taken out later after the fracture has healed. After the surgery, the ankle is placed in a splint or a brace and crutches are used.
What is involved in the recovery from surgery and when can I return to sports?
The time to full weight bearing, rehabilitation course, and return to sports is dependent on the specific fracture type, the surgical fixation, the bone quality, and the surgeon’s preferences. Typically, you will be in a brace or a cast for 4-6 weeks with crutches. It is very important to keep your ankle elevated for the first couple of weeks after surgery to decrease the swelling. It is important to work on range of motion and strengthening as directed by your physician. It is also important to have full range of motion and strength before attempting to return to sports. Return to sports is typically 4-6 months, but may be longer based on the severity of injury.
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