Broken Ankle (Ankle Fracture)

The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli.
A fracture is a partial or complete break in a bone. In the ankle, fractures involve the far (distal) ends of the tibia and/or the fibula. Some distal tibia fractures can involve the rear (posterior) part of the bone, which also are known as posterior malleolar fractures. Ankle fractures can range from less serious avulsion injuries (small pieces of bone that have been pulled off) to severe, shattering-type breaks. Some fractures also may involve injuries to important ankle ligaments that keep the ankle in its normal position. Ankle fractures are commonly caused by the ankle twisting inward or outward.

Causes

Symptoms

One or all of these signs and symptoms may accompany an ankle fracture:

• Pain at the site of the fracture, which can extend from the foot to the knee
• Swelling, which may occur along the length of the leg or be more localized at the ankle
• Blisters, which should be treated promptly
• Bruising
• Decreased ability to walk. It is possible to walk or bear weight upon the ankle with less severe fractures. Never rely on walking as a test of whether the ankle is fractured.
• Bones protruding through the skin. This condition is known as an open ankle fracture. These types of ankle fractures require immediate treatment to avoid problems like infection.

Most patients with ankle fractures are treated in an emergency room or a doctor’s office. An X-ray of the damaged ankle may be taken to determine what the fracture looks like, which bones are broken, how separated or displaced the bones are, and the condition of the bone itself. The X-ray will help determine the proper course of treatment.

Potential Treatments

• Elevation and Ice

Swelling is often seen after an ankle fracture. By limiting the amount of swelling, the pain from the ankle fracture can be decreased and further damage to the surrounding soft tissue may be prevented. Elevating the ankle and icing the affected area can help to limit swelling.

• Splint

A splint may need to be placed to support the broken ankle. The splint usually remains for several days. A splint allows for room to accommodate swelling. If the damaged ankle is not displaced, the splint may be applied immediately without moving the broken ankle. However, if the bones are displaced and/or the ankle joint is dislocated, a closed reduction is performed while the splint is placed. This treatment involves setting the tibia and/or fibula bones and ankle joint to improve the position and pain at the ankle. This treatment may require anesthesia.

• Rest/No Weight Bearing

Most patients require some period of rest with no weight being put upon the ankle. Crutches, walkers, and wheelchairs allow patients to keep weight off the ankle. Many factors can determine which is the best choice for an individual patient. The type of ankle fracture will determine when patients can start to stand and walk on their injured ankle. In many cases, a patient will not be able to place any weight on the ankle for several days, weeks, or even months. This is a determination that must be made by a foot and ankle orthopaedic surgeon.

• Cast/Fracture Boot Immobilization

Some ankle fractures can be treated without surgery. These usually are injuries where one bone is minimally displaced. Such fractures can be treated simply with a period of immobilization. Once the initial swelling improves over the first several days, either a cast or a fracture boot can be applied to the ankle to properly protect and immobilize it. Both a cast and a boot can provide adequate protection to the ankle. A cast cannot get wet or be removed without special tools. A boot can be removed for bathing and sleeping. The type of fracture and the physician’s judgment will determine the best type of immobilization. The cast or boot is worn until the fracture is fully healed, which usually takes 2-3 months.

• Surgery

Whether or not a patient requires surgery will largely depend on the appearance of the ankle joint on the X-ray and the specific type of fracture. Badly displaced fractures and fractures of both the tibia and fibula commonly need surgery. Restoring alignment of the broken bone is essential to full recovery because ankle arthritis can occur if a fracture heals improperly. The best way to minimize the risk of arthritis is to restore the ankle to as close to normal as possible.
The surgical treatment is known as an open reduction and internal fixation or ORIF. An outer or lateral incision is made at the ankle if the fibula bone is broken. An inner or medial incision is made at the ankle if the distal tibia bone is broken. The injured bones are set properly through these incisions and kept in place with metal plates and screws. As the ankle heals after surgery, the joint is protected with restricted activity and a cast or fracture boot. The cast or boot is worn until the fracture is fully healed, which usually takes 2-3 months.

Your foot and ankle orthopaedic surgeon will take additional X-rays while the bones heal to make sure that changes or pressures on the ankle don’t cause the bones to shift.

Usually there are few complications from a broken ankle, although there is a higher risk among diabetic patients and those who smoke. Your surgeon may prescribe a program of rehabilitation and strengthening. Range-of-motion exercises are important, but keeping weight off the ankle is just as important.
A child who breaks an ankle should be checked regularly for up to two years to make sure that growth proceeds properly without deformity or uneven leg length.