Author(s): Craig Van Dien, MD, Eric Liu, DO and Tomas Salazar, MD
Originally published: September 21, 2015 Last updated: July 30, 2020
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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 “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 Additional classification systems include Danis-Weber and OA/OTA (please see supplemental assessment).

Epidemiology

Ankle fractures account for 9.3% of all fractures,6 over 50% of traumatic foot and ankle fractures,9 and are the 4th most common fracture in the elderly.7 The incidence in the adult population is dependent upon multiple factors, including age, sex, specific sport, and competitive level in athletics.5  Mean patient age, depending on the study, ranges from the 40’s to 50’s, with an overall female predominance. 41,42 Female incidence increases between the ages of 30-39 and 60-69, while the male incidence either follows a more uniform distribution42 or decline after the age of 20.41 Amongst ankle fractures, unimalleolar injuries occur most commonly (60-70%; lateral > medial),41 followed by bimalleolar (15-20%), and trimalleolar (7-12%) respectively.1 Traumatic medial malleolar fractures have the highest proportion of open injuries.9 Using the OA/OTA fracture classification, type B fractures comprise the greatest percentage of ankle fractures, followed by Type A and Type C.42

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.

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 assess 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.13 External 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 Ankle Rules. Those that present with bony tenderness at the tip or posterior edge of the lateral or medial malleolus, or patients who are unable to bear weight immediately and in the emergency department should have a radiographic series of the ankle.26

Ultrasound (US) has emerged as an inexpensive modality that may have utility in the assessment of ankle fractures.27,28,43 For example, Hedelin et al. highlighted the potential benefits of triaging emergency room patients presenting with ankle trauma in excluding significant fractures, and reducing unnecessary radiographs.28 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.43

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).29 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 closely associated with syndesmotic injury.29 

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.29

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.15

Following surgical intervention and immobilization, Segal et al. identified that all ankle fracture patients demonstrated gait abnormalities and a reduction in quality of life (using short form 36 health survey) compared to healthy controls.  Amongst fracture type, the following was identified:

  1. Patients with unimalleolar fractures ambulated with faster velocity than bimalleolar fracture.
  2. Patients with unimalleolar fractures demonstrated a longer step length (uninvolved limb) and higher single limb support than bi- and trimalleolar fractures.
  3. Patients with unimalleolar fractures were identified to be in better clinical condition (according to the American Orthopaedic Foot and Ankle Score clinical assessment) than bi- and trimalleolar fractures
  4. Patients with unimalleolar fractures showed a significantly greater walking distance during the 6-minute walking test as compared trimalleolar fracture

No significant differences were identified between bi- and trimalleolar fractures in all measures noted above.30

A recent systematic review and meta-analysis evaluated the prognosis of physical function following ankle fractures, focusing of 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.31

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.

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-weightbearing before referring to orthopedic surgery for further evaluation and consideration of surgical management. Unstable ankle fracture management may include open reduction and internal fixation procedures or casting.32 Regarding long-term outcomes in the adult population, a 2012 Cochrane Review concluded that insufficient evidence exists to support either the conservative (casting) or surgical intervention for ankle fractures.8   This was redemonstrated by Willet, et al who 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.32

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 x-rays at 6 weeks with the cast removed and for skin integrity.16 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 orthosis immobilization had similar ankle function and rates of fracture union.33 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 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. However, the overall benefit of rehabilitation following immobilization is with limited support.  For instance, 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 Similarly, a recent randomized controlled trial investigated the utility of a supervised exercise program with education versus education alone in isolated uncomplicated ankle fractures following immobilization. The study concluded that there were no significant differences between the two groups at 1, 3, and 6 months in improvements in activity limitation and quality of life.34

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 understood. 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

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).35 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.35  

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

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 A 2019 study evaluating ankle function and rate of fracture union supports that 3 weeks of immobilization was non-inferior to 6 weeks.33

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 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

Three-dimensional (3D) printing may offer utility in fracture management. Yang et al created true to size 3D models of trimalleolar fractures that allowed for improved preoperative planning resulting in reduced operative time and blood loss and improved physician-patient communication.36 Benefit was similarly suggested in malunited ankle fractures.37

Low intensity pulsed ultrasound (LIPUS) may confer benefit to patients experiencing post-traumatic and post-surgical fracture nonunion in the foot and ankle. Better responses (fracture union and patient reported outcomes) were seen in tibia/ankle nonunion, followed by hindfoot and midfoot/forefoot arthrodesis procedures respectively, though this was without statistical significance. 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).38

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

Further research is needed exploring best management strategies/options for osteoporotic and pediatric ankle fractures (though this was not the scope of this article).39,40

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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). Originally published, 9/21/2015.

Author Disclosure

Craig Van Dien, MD
Nothing to Disclose

Eric Liu, DO
Nothing to Disclose  

Tomas Salazar, MD
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