Adult Ankle Fractures (ankle and foot soft tissue injuries and fractures)

Author(s): Jason L. Zaremski, MD, Robert M Donlan, DO , Daniel C Herman, MD, PhD

Originally published:09/21/2015

Last updated:09/21/2015

1. DISEASE/DISORDER

Definition

Ankle fractures refer to any fracture involving the bones of the talocrural joint, namely the distal aspects of the tibia and fibula, and the talus. This article will focus strictly on fractures of distal tibia and fibula in the adult patient. Information on foot and ankle stress fractures and other overuse injuries can be found in “Ankle and Foot Overuse Disorders”. Information on ligament injuries and ankle sprains may be found in “Ankle Sprain”. Pediatric ankle fractures typically involve the physis and are not within the scope of this article.

Etiology

Ankle fractures typically result from a sudden, forceful twisting movement in multiple planes. Such movements almost always include inversion or eversion.1 However, the exact combination of forces that produce a particular pattern of fracture is still not clear. The Lauge-Hansen classification system for ankle fractures attempts to link mechanism of injury and fracture pattern.2 However, one report found that nearly 53% of the ankle injuries studied did not coincide with the predicted injury pattern based on mechanism of injury, and that 14% had a common fracture pattern not explained by the various combination of forces proposed by Lauge-Hansen.3 Similarly, a recent small study found that the mechanisms proposed by Lauge-Hansen were only 58% accurate in predicting actual fracture patterns.4 Another additional classification system is the Danis-Weber system (see Table 2 and the “Supplemental Assessment” section).

Epidemiology

The incidence of ankle fractures in the adult population is dependent upon multiple factors, including age, sex, specific sport, and competitive level in athletics.5 Ankle fractures have been estimated to account for 9.3% of all fractures6 and are the 4th most common fracture in the elderly.7 The incidence has been estimated between 71-122/100,000 for all patients.8-9 A majority of ankle fractures involve only one malleolus (60-70%), followed by bimalleolar (15-20%), and trimalleolar (7-12%).1 Men and women have different age-distributions of ankle fractures, with incidence rates higher in young men and elderly women.1

Patho-Anatomy

The trimalleolar complex is comprised of the medial, lateral, and posterior malleoli. This complex articulates with the talus and is supported by a complex network of ligaments, effectively forming a “ring” around the talocrural joint. Depending on the position of the foot and the direction of the twisting force, one or more of these ligaments and malleoli can be injured. The lateral malleolus is implicated with an inversion position and an adduction force, which stresses the lateral ligaments. If forceful enough, this may avulse the lateral malleolus. If the twisting force continues, the talus may shift and impact the medial malleolus, causing an oblique fracture. The medial malleolus is implicated in an eversion position and an abduction force, stressing the deltoid ligament complex and potentially leading to a medial malleolus avulsion fracture. Again, if the force continues, the talus will shift laterally and impact the lateral malleolus, causing an oblique fracture. The addition of an axial compression force to the everted ankle can injure the posterior malleolus. If external rotation of the talus is added, syndesmotic injury and proximal fibula fractures (e.g. Maisonneuve fractures) may occur. According to original research, the most common mechanisms included supination-external rotation fractures accounting for 40–75% of ankle fractures; supination-adduction for 10–20%; pronation-abduction for 5–21% and pronation-external rotation for 7–19%.10

Associated Conditions

Structures in proximity to the ankle joint can potentially be associated with malleolar fractures, including the deep peroneal nerve, tibial nerve, and both anterior and posterior tibial arteries. Suspicion for injury to the talus and more distal structures, such as the navicular and fifth metatarsal base, is also warranted.

2. ESSENTIALS OF ASSESSMENT

History

The activity, mechanism, and timing of injury should be noted as this can help target areas for more thorough physical examination and tailor treatment. Competition level (if participating in athletics) as well as associated symptoms such as weightbearing status, paresthesias, or cold feet/loss of distal pulses should also be noted. Additional areas include past fractures or stress fractures as well as if there are any disorders of bone health.

Physical Examination

Examination should begin with gross visual inspection. Any deformity, malalignment, edema, ecchymosis, or erythema should be noted. Range of motion assessment is less informative in the acute setting as the patient will have abnormalities due to pain and guarding. Next, the lateral, medial, and posterior malleoli should be palpated. The distal aspects of both the tibia and fibula should be palpated, as well as the proximal fibula in cases of suspected eversion injury.11 The dorsal proximal foot should also be palpated to asses for possible tarsal bone fracture, particularly when the mechanism of injury is from a motor vehicle accident. Some ankle fractures may present with concomitant syndesmotic injury; therefore, the integrity of the syndesmosis should be assessed via a combination of provocative tests, including but not limited to the external rotation stress test, squeeze test, and Cotton test.12 Neurovascular status of the ankle/foot should also be assessed.

Functional Assessment

Acute ankle fractures often significantly reduce a patient’s functional ability via impaired gait and weightbearing and secondarily due to pain. The ability to bear weight should be assessed, but further assessment of ankle stability and function should be delayed until pain, edema, and guarding diminish.

Laboratory Studies

While laboratory studies are not required for the assessment of acute ankle fractures, it is reasonable to consider pathophysiological reasons (such as osteoporosis) for a fracture. Assessment with Calcium, alkaline phosphatase, 25-hydroxycalciferol, and parathyroid hormone levels are reasonable for a first line screen in cases where this is a suspected contributing factor.

Imaging

Standard radiographs of the injured ankle with three views (Anterior-Posterior, Lateral, and Mortise) should be obtained in accordance with the Ottawa Ankle Rules (see below) to help determine the location of a fracture and thus the stability of the ankle.11 Suspected syndesmotic injury should first be evaluated by measuring the tibiofibular clear space and overlap, although there is some question about the predictive value of these measurements.13External rotation stress radiographs are used to assess competency of the deltoid ligament complex. A medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption.14 MRI is generally not required, but may be useful when suspicion for syndesmotic injury is high or atypical fracture pattern is present on radiographs.3 If there is concern of the extent of the bony anatomy that cannot be fully visualized on radiographs, a CT scan is indicated. Radiographs are indicated based upon the Ottawa Rules (see Table 1).

Supplemental Assessment

Assessment of ankle stability following fracture is crucial to determining the proper treatment pathway. It should be based on a combination of physical examination findings and radiographic evidence. In general, stable ankle fractures include uni-malleolar fractures with or without limited contralateral ligament injury. Unstable ankle fractures involve bi- or tri-malleolar fractures, bi-malleolar equivalent fractures, or a uni-malleolar fracture with significant contralateral ligament injury.

Various classification systems exist for ankle fractures. The two most commonly used are the Danis-Weber system and the Lauge-Hansen system (see tables 2 and 3). The Danis-Weber systems looks only at the lateral malleolus and classifies fractures as A (distal to the mortise), B (at the level of the mortise), and C (proximal to the mortise). Weber C fractures likely involve syndesmotic injury. The Lauge-Hansen system involves both the lateral and medial malleoli and classifies fractures according to the ankle movement involved in the injury.10,15

Early Prediction of Outcomes

Fractures involving more than one malleolus have been shown to have poorer outcomes than uni-malleolar fractures. A higher degree of ankle dorsiflexion following a period of immobilization has been found to predict better functional outcomes.15

Environmental

The fracture classification systems have not been shown to be predictive of healing, but do assist with operative versus non-operative management decision making.16

Social Role and Social Support System

Treatment outcomes involve the cooperation of the patient, the parents (in pediatrics), physical therapists, and other family members. Good communication during the initial evaluation and setting patient expectations for length of immobilization and length of rehabilitation time can ease the psychological burden of not being able to walk and/or be active for weeks to months.

Professional Issues

The return to baseline activities, such as the return to play in athletes and return to work are important aspects in the management of ankle fractures. It is also important to have close communication with the physical therapists who will assist in the rehabilitation process as well as with an Orthopaedic Surgeon should a second opinion be needed.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or Current Treatment Guidelines

In general, displaced and unstable ankle fractures (as noted in the supplemental assessment section above) should be immobilized in a neutral positon and the patient made non-weightbearing before referring to orthopedic surgery for further evaluation and consideration of surgical management. Non-displaced (<1mm) stable fractures may be managed conservatively and will be the focus of the following sections.1

At Different Stages

Standard PRICE (Protection, Rest, Ice Compression, Elevation) therapy should be started upon acute presentation to reduce swelling and attenuate pain. Patients may be made non-weightbearing and placed in a lower extremity splint with the ankle in a neutral position for 3-5 days if symptoms dictate. The assistance of a compression dressing may also be warranted depending on the severity of the swelling.

At follow-up, definitive treatment is dictated by the type of fracture. Weber A fractures of the lateral malleolus involve application of a short leg non-weight bearing cast with use of crutches versus use of a weight bearing cast with a cast shoe. Immobilization is continued for a total of approximately 6-8 weeks with a skin check at 3-4 weeks. Weber B fractures can be either be stable or unstable, depending on the competence of the medial deltoid ligament complex. Stable Weber B fractures do not necessarily require follow-up radiography,17although it has been argued that Weber B fractures have the potential to become unstable and that they should be re-imaged at 2 weeks to assess for proper alignment before mature callous sets in.16 If there is continued appropriate alignment at the 2 week mark, then repeat xrays at 6 weeks with the cast removed and for skin integrity.16 Gentle ankle range of motion exercises should be started at approximately 6-8 weeks, though may be started earlier in Weber A fractures as opposed to Weber B fractures. Once the patient has no further pain at the site of fracture and there is radiographic evidence of union, progressive weightbearing and further rehabilitation may continue. Weber C fractures are typically unstable due to syndesmotic injury and should be referred to orthopedic surgery for further evaluation. Isolated medial and posterior malleolar fractures are rare. However, if they are truly isolated and non-displaced, the same treatment regimen can be used that is used for Weber A fractures.

Rehabilitation of ankle fractures is centered on restoration of the functional capacity of the ankle joint following immobilization. This includes a focus on range of motion, strength, and proprioception. A Cochrane review of 38 studies using various rehabilitation interventions found limited evidence to support intervention during the immobilization period following both surgical and non-surgical treatment. Additionally, there is no evidence to support stretching or manual therapy as beneficial compared to a standard program after the period of immobilization.18

Coordination of Care

In addition to maintaining communication with physical therapists, it is important to communicate with the patient’s place of employment on their behalf and with their consent. Patients that suffer ankle fractures have been shown to suffer from high rates of unemployment or disability shortly after their injury.19 Communication with employers may include regular updates of work limitations and expectations regarding the duration of different phases of recovery.

Patient and Family Education

It is important to educate patients and their family members that the healing process is only the first step in the road to recovery. The second part, the rehabilitation after the immobilization process is complete, is a slow process that may take longer than the immobilization period.

Measurement of Treatment Outcomes

Typically, most patients return to full, pre-injury daily activities in 6-10 weeks. Return to pre-injury levels during sports is less well-known. Isolated malleolar fractures likely present no significant barriers to a full return. However, a recent study found that only 27% of athletes with either a bimalleolar or trimalleolar fracture returned to pre-injury levels of sports competition. 18% were unable to return to any sporting activity.20 Level of ankle dorsiflexion after cast removal has also been studied as a predictor of outcome.21

Translation into Practice

Ankle fractures may be due to a single, acute injury mechanism, but the recovery process involves multiple health care providers as well as family members. Education and setting patient expectations early will provide a framework on probability of healing time and returning to previous functional independence.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting Edge Concepts and Practice

Newer data on Weber B fractures has indicated that when treated non-operatively shortening the duration of cast time may improve long term outcomes.16

Emerging/Unique Interventions

Due to osteoporosis and fragility fractures, the American Orthopaedic Association developed the “Own the Bone” program as a quality improvement program to address the osteoporosis treatment gap and prevent subsequent fragility fractures. Through a clinically-proven, web-based patient registry and 10 prevention measures, Own the Bone provides tools and helps institutions to establish a fracture liaison service (FLS) in which a care coordinator (such as a nurse, nurse practitioner or a physician assistant) ensures that post-fracture patients are identified and receive appropriate evaluation, diagnosis, and treatment, under the supervision of their primary care physician, orthopaedic surgeon or osteoporosis specialist.22-23

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the Evidence-Based Knowledge

When radiographs are negative for a fracture, literature has shown that a vibrating tuning fork may be useful to detect a fracture at the potential fracture site. However, data is not reliable or accurate for widespread clinical use.24-25 Gaps in the clinical use of existing evidence-based knowledge regarding the use of radiographs and treatment of osteoporosis persist.26-27

REFERENCES

  1. Eiff MP, Hatch R. Fracture Management for Primary Care. 3rd Edition. Elsevier Saunders, 2012: 258-75.
  2. Yde J. The Lauge Hansen Classification of Malleolar Fractures. Acta Orthopaedica 1980; 51(1-6): 181-92.
  3. Gardner MJ, et al. The Ability of the Lauge-Hansen Classification to Predict Ligament Injury and Mechanism in Ankle Fractures: An MRI Study. J Orthop Trauma 2006; 20(4): 267-72.
  4. Kwon JY, et al. A Novel Methodology for the Study of Injury Mechanism: Ankle Fracture Analysis Using Injury Videos Posted on YouTube.com. J Orthop Trauma 2010; 24-8: 477-82.
  5. Court-Brown CM, McBirnie J, Wilson G. Adult Ankle Fractures – An Increasing Problem? Acta Orthop Scand 1998; 69(1): 43-47.
  6. Court-Brown CM, Caesar B. Epidemiology of Adult Fractures: A Review. Injury, Int J Care Injured 2006; 37: 691-97.
  7. Barrett JA, et al. Fracture Risk in the U.S. Medicare Population. J Clin Epidemiol 1999; 52(3): 243-49.
  8. Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev. 2012 Aug 15;8:CD008470.
  9. Thur CK, Edgren G, Jansson KÅ, Wretenberg P. Epidemiology of adult ankle fractures in Sweden between 1987 and 2004: a population-based study of 91,410 Swedish inpatients. Acta Orthop. 2012 Jun;83(3):276-81.
  10. Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental roentgenologic investigations. Arch Surg 1950;60:957-85.
  11. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993; 269: 1127–1132.
  12. Sman AD, Hiller CE, Refshauge KM. Diagnostic Accuracy of Clinical Tests for Diagnosis of Ankle Syndesmosis Injury: A Systematic Review. Br J Sports Med 2013; 47: 620-28.
  13. Nielson JH, et al. Radiographic Measurements Do Not Predict Syndesmotic Injury in Ankle Fractures: An MRI Study. Clin Orthop Relat Res 2005; 436: 216-21.
  14. Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status onmedial clear space measurements. J Orthop Trauma. 2006 Jan;20(1):11-8.
  15. Harper MC. Ankle fracture classification systems: a case for integration of the Lauge-Hansen and AO-Danis-Weber schemes. Foot Ankle. 1992 Sep;13(7):404-7. Review.
  16. Van Schie-Van der Weert EM, Van Lieshout EM, De Vries MR, Van der Elst M, Schepers T. Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures. Arch Orthop Trauma Surg. 2012 Feb;132(2):257-63.
  17. Martin, AG. Weber B Ankle Fracture: An Unnecessary Fracture Clinic Burden. Injury 2004; 35(8): 805-8.
  18. Lin CWC, Donkers NAJ, Refshauge KM, et al. Rehabilitation for Ankle Fractures in Adults. Cochrane Database Syst Rev. Nov 14, 2012; CD005595.
  19. Thakore RV, Hooe BS, Considine P, Sathiyakumar V, Onuoha G 2nd, Hinson JK, Obremskey WT, Sethi MK. Ankle fractures and employment: a life-changing event for patients. Disabil Rehabil. 2015;37(5):417-22.
  20. Hong CC, Roy SP, Nashi N, Tan KJ. Functional Outcome and Limitation of Sporting Activities After Bimalleolar and Trimalleolar Ankle Fractures. Foot Ankle Int 2013; 34(6): 805-10.
  21. Hancock MJ, Herbert RD, Stewart M. Prediction of Outcome After Ankle Fracture. J Orthop Sports Phys Ther 2005; 35(12): 786-92.
  22. Burge R, Dawson-Hughes, B, Solomon DH, Wong BJ, King, A, Tosteson, A; Incidence and economic burden of osteoporosis-related fractures in the United. J Bone Mineral Res. 2007 Mar;22(3):465-75.
  23. http://www.ownthebone.org/about-own-the-bone.aspx. Accessed March 18th, 2015.
  24. Moore MB. The use of a tuning fork and stethoscope to identify fractures. J Athl Train. 2009 May-Jun;44(3):272-4.
  25. Mugunthan K, Doust J, Kurz B, Glasziou P. Is there sufficient evidence for tuning fork tests in diagnosing fractures? A systematic review. BMJ Open. 2014 Aug 4;4(8).
  26. Brehaut JC, Stiell IG, Visentin L, et al. Clinical decision rules “in the real world”: how a widely disseminated rule is used in everyday practice. Acad Emerg Med. 2005;12:948-956.
  27. Feldstein A, Elmer PJ, Orwoll E, Herson M, Hillier T. Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures: a gap in evidence-based practice guideline implementation. Arch Intern Med. 2003 Oct 13;163(18):2165-72.

Author Disclosure

Jason L. Zaremski, MD
Nothing to Disclose

Robert M Donlan, DO
Nothing to Disclose

Daniel C Herman, MD, PhD
Nothing to Disclose

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