Author(s): Shane Mario Andre Drakes, MD, Anusha Lekshminarayanan, MD, Petra Aboulhosn, MD
Originally published: September 21, 2015 Last updated: February 15, 2024
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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 the PM&R KnowledgeNOW topic 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 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 Additional classification systems include Danis-Weber and OA/OTA (please see supplemental assessment).

Epidemiology

Ankle fractures account for 9.3% of all fractures and are the 4th most common fracture in the elderly.5–7 Ankle fracture incidence is about 4.22/10,000 person-years.8 The incidence in the adult population is dependent upon multiple factors, including age, sex, specific sport, and competitive level in athletics.9 Bimodal distribution of ankle fracturesamong adolescent males and elderly females has been noted.8,10 Scheer et al found a higher rate of ankle fractures among the Caucasian race.11 Over 50% of foot and ankle fractures are the result of trauma.5–7 The most common mechanism of injury was falls (35.68%), followed by sports related injuries (35.26%).11 Functional outcomes were strongly related to patient characteristics, such as female sex, obesity, and substance use.12

Amongst ankle fractures, unimalleolar injuries occur most commonly (60-70%; lateral > medial),8 followed by bimalleolar (15-20%), and trimalleolar (7-12%) respectively.1 Traumatic medial malleolar fractures have the highest proportion of open injuries.7 Using the OA/OTA fracture classification, type B fractures comprise the greatest percentage of ankle fractures, followed by Type A and Type C.10

Patho-anatomy

The ankle joint is a hinge synovial joint made up of the trimalleolar complex comprised of the medial, lateral, and posterior malleoli. Stability is achieved due to the bony articulation with the talus and a complex network of ligaments, syndesmosis and muscles. 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%.13

Associated conditions

Neurovascular structures in proximity to the ankle joint can potentially be injured in malleolar fractures. Navicular and fifth metatarsal base fractures should be ruled out.

Essentials of Assessment

History

Alcohol and tobacco use are important predictors of bone healing.14,15 Pertinent history includes mechanism of injury, competitive versus recreational setting, baseline functional status, inability to bear weight or any sensorimotor changes. Goals of care should also be established.

Physical examination

Examination should begin with gross visual inspection. On inspection, any deformity, edema, ecchymosis, or erythema should be noted. Range of motion assessment in the acute setting is limited by pain and guarding. Next is palpation of the lateral, medial, and posterior malleoli, distal aspects of the tibia and fibula, as well as the proximal fibula in cases of suspected eversion injury.16 The dorsal proximal foot should also be palpated to assess for possible tarsal bone fracture, particularly when the mechanism of injury is motor vehicle accident. Some ankle fractures may present with concomitant syndesmotic injury. Special tests to assess syndesmotic injury include the external rotation stress test, squeeze test, and Cotton test.17 Strength, sensation, and neurovascular status of the ankle/foot should also be assessed.

Functional assessment

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

Laboratory studies

Laboratory studies including calcium, alkaline phosphatase, 25-hydroxycalciferol, and parathyroid hormone levels are done to rule out metabolic causes, endocrinopathies and osteoporosis.

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 (OAR- see below) to help determine the location of a fracture and thus the stability of the ankle.16 The OAR is highly sensitive and cuts unnecessary medical costs.18 Obtaining radiographs should not delay the urgent reduction of the clinically obvious, deformed ankle.14 Radiographs are indicated based upon the Ottawa Ankle Rules. Those that present with pain or bony tenderness at the tip or posterior edge of the lateral or medial malleolus (and 6 cm proximally), or patients who are unable to bear weight immediately and in the emergency department should have a radiographic series of the ankle. Weight bearing is determined by the patient’s ability to take four steps.19Suspected 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.20Weight bearing and external rotation stress radiographs are used to assess competency of the deltoid ligament complex injury.21 A medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption.22 Full tibia and fibula length X-rays are valuable to rule out proximal fibula fracture in Maisonneuve injury.19 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 Weight bearing cone-beam CT is also used to evaluate syndesmotic injuries.23  CT scan is also helpful for pre-operative planning for management of unstable fractures and for diagnosing posterior malleolar fractures.19

Ultrasound (US) has emerged as an inexpensive modality with utility in the assessment of ankle fractures. 24–26 Hedelin et al. highlighted the benefit of US in triaging emergency room patients with significant ankle fractures .25 Moreover, Shojaee et al. found US to be both highly sensitive 98.9% (95% CI: 93.5%-99.9%) and specific 86.4% (95% CI: 71.9%-94.3%) for fracture identification.26 US is a good tool to detect soft tissue injury including tears of the tibiocalcaneal and tibionavicular portions of the deltoid ligament. US is ideal for patients with continued ankle pain and negative radiography.19,21 Serial US may be used to assess fracture healing, with visualization of callus formation and fracture union. This is significantly useful in determining return to play. Fracture union can be diagnosed on average 2 weeks earlier with US, when compared with radiographs.19

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 unimalleolar fractures with or without limited contralateral ligament injury. Unstable ankle fractures involve bi- or trimalleolar fractures, bimalleolar equivalent fractures, or a unimalleolar fracture with significant contralateral ligament injury.

The Lauge-Hansen system categorizes ankle fractures based on foot position (FP) and directional forces (DF) at the time of injury. The four primary categories include supination (FP) external rotation (DF), supination (FP) adduction (DF), pronation (FP) external rotation (DF), and pronation (FP) abduction injuries (DF).27 Each category is further divided into subgroups.

The Danis-Weber system categorizes fractures into Type A (distal to the tibial plafond), Type B (at the level of the tibial plafond), and Type C (proximal to the tibial plafond) based on radiographic features. Type C fractures are often associated with syndesmotic injury.27 

The AO/OTA system classifies ankle fractures as infrasyndesmotic, transsyndesmotic, and suprasyndesmotic with further subgroup classification to reflect the existence of medial or posterior malleolar involvement. This classification system is similarly based on radiographic features.27

Early prediction of outcomes

Fractures involving more than one malleolus have been shown to have poorer outcomes than unimalleolar fractures. A higher degree of ankle dorsiflexion following a period of immobilization has been found to predict better functional outcomes.28

Following surgical intervention and immobilization, Segal et al. identified that all ankle fracture patients demonstrated gait abnormalities and a reduction in quality of life compared to healthy controls. Patients with unimalleolar fractures had better clinical outcomes; better cadence, longer step length, more single limb support and greater walking distances with 6-minute walking test. No significant differences were identified between bi- and trimalleolar fractures in these measures noted.29

A recent systematic review and meta-analysis evaluated the progno6-minutehysical function following ankle fractures, focusing on activity limitation. Surgical and non-surgical patients had significant improvements in activity limitation at 3 months followed by incremental improvements between 3 and 6 months. Gains plateau thereafter, with some residual activity limitations persisting by 24 months.30

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.31

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 with the patient and family 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 orthopedic surgeon should a second opinion be needed.

Rehabilitation Management and Treatments

Available or current treatment guidelines

In general, displaced and unstable ankle fractures should be immobilized in a neutral position and the patient made non-weight bearing before referring to orthopedic surgery for further evaluation and consideration of surgical management, preferably within 2 days after the inciting trauma.32 Unstable ankle fracture management may include open reduction and internal fixation procedures or casting.33 Willet et al found that close contact casting produced similar results to surgical intervention at 6 months using both subjective and objective scoring measures. Moreover, there were fewer adverse events.33

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. Ice compression can be achieved using evaporative coolants as well.34 Bracing was favorably received compared to plaster cast among patients with avulsion fractures of the lateral malleolus.35

Patients may be made non-weight bearing 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. Wang et al recommended ankle pump exercises at the frequency of three to four seconds to promote lower limb hemodynamics and prevent deep vein thrombosis.36

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 have the potential to become unstable. They should be re-imaged at 2 weeks to assess for proper alignment before mature callus sets in.31,37 If there is continued appropriate alignment at the 2-week mark, x-rays are repeated at 6 weeks, the cast is removed and  skin integrity assessed.31 Though stable Weber B fractures are traditionally immobilized for 6 weeks, a recent non-inferiority trial demonstrated that patients receiving 3 weeks of casting or orthotic immobilization had similar ankle function and rates of fracture union.38 A meta-analysis confirmed the non-inferiority of removable orthosis.39 Using the Olerud-Molander Ankle Score (OMAS), Haque et al demonstrated that plaster cast immobilization provided similar outcomes in terms of ankle function when compared with fixed angle removable ankle orthosis at 2-year follow up.15 Gentle ankle range of motion exercises have been conventionally 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 weight bearing, 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, as Weber A fractures, can be used. Evidence suggests plate fixation and locked intra-medullary nails, respectively, are recommended for elderly and young adults with unstable ankle fractures.40,41

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. Gait assessment instruments including step and stride lengths, swing time, single limb support, cadence can be beneficial to measure and follow up on gait alterations.42 A randomized controlled trial investigated the utility of a supervised exercise program with education following immobilization versus education alone in isolated uncomplicated ankle fractures. There were no significant differences in activity limitation and quality of life between the two groups at 1, 3, and 6 months.43 Weight bearing as tolerated during post-operative rehabilitation led to return to employment in 1 month and return to sports activities at 8 weeks.44

Secondary treatment interventions

Among the elderly, the focus should be on preventing falls. Interventions include avoiding polypharmacy, addressing visual deficits, assessing home safety, and treating osteoporosis. Additionally, emphasis should be placed on implementing a multi-component exercise regimen that includes strengthening exercises (multidirectional hopping program), resistance training (dumb bells, elastic bands, leg press machine), dynamic stability training, eccentric exercises (with equipment), gait, and coordination training.45,46

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 with ankle fractures reported high rates of unemployment or disability shortly after their injury.47 Communication with employers may include regular updates of work limitations and expectations regarding the duration of different phases of recovery. Timely referral to orthopedic surgeon (within 2 days of trauma) for unstable fractures could prevent poor outcomes including ankle instability and post-traumatic osteoarthritis.32

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 occurs around 8 weeks.44 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.48 Level of ankle dorsiflexion after cast removal has also been studied as a predictor of outcome.49

Patient reported outcome measures (PROMs) are useful tools for assessing functional outcomes. A systematic review by Ng et al. identified 5 specific PROMs that have been applied to ankle fractures: short form 36 health survey, short musculoskeletal function assessment (SMFA), ankle-fracture outcome of rehabilitation measure (A-FORM), the Olerud and Molnader questionnaire, and the lower extremity functional scale (LEFS).15,50 The study further evaluates the psychometric properties of these scales (including internal consistency, test-retest reliability, validity, floor-ceiling effects, and minimally important clinically differences), with the authors recommending use of the A-FORM, LEFS, and SMFA when assessing PROMs.50  

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.

Cutting Edge/Emerging and Unique Concepts and Practice

Newer data on non-operatively managed Weber B fractures has indicated that shortening the duration of cast time may improve long term outcomes.31 A 2019 study evaluating ankle function and rate of fracture union noted that 3-week immobilization was non-inferior to 6 weeks.38

Emerging/unique interventions

Due to osteoporosis and fragility fractures, the American Orthopedic 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 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, orthopedic surgeon or osteoporosis specialist.51,52

Three-dimensional (3D) printing may offer utility in the management of trimalleolar and malunited ankle fractures.53 Yang et al created true to size 3D models of trimalleolar fractures which allowed for improved preoperative planning, reduced operative time, reduced blood loss and improved physician-patient communication.54,53

Arthroscopy is increasingly used for surgical treatment of ankle fractures. Contrary to prior literature, fragment size in posterior malleolar fractures does not indicate criticality. Large, isolated fractures with adequate articular congruity could be treated non operatively.55

Low intensity pulsed ultrasound (LIPUS) may confer benefit to patients experiencing post-traumatic and post-surgical fracture nonunion in the foot and ankle. Use amongst participants was 20 minutes daily, with treatment ranging from 3-15 months (average for 6.1 months for those patients who achieved bone union).56

Gaps in the Evidence-Based Knowledge

When radiographs are normal, 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.57,58 A spring loaded ankle trainer led to faster post-operative recovery of ankle fractures.59

Further research is needed to explore the best management strategies/options for osteoporotic and pediatric ankle fractures (though this was not the scope of this article).60,61

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Original Version of the Topic

Jason L. Zaremski, MD, Robert M Donlan, DO, Daniel C Herman, MD, PhD. Adult Ankle Fractures (ankle and foot soft tissue injuries and fractures). 9/21/2015

Previous Revision(s) of the Topic

Craig Van Dien, MD, Eric Liu, DO and Tomas Salazar, MD. Adult Ankle Fractures (Ankle and Foot Soft Tissue Injuries and Fractures). 7/30/2020

Author Disclosure

Shane Mario Andre Drakes, MD
Nothing to Disclose

Anusha Lekshminarayanan, MD
Nothing to Disclose  

Petra Aboulhosn, MD
Nothing to Disclose