Ankle Fracture

What is an ankle fracture?

The ankle joint is composed of 3 bones:

  • tibia (shin bone),
  • fibula and
  • talus.

An ankle fracture refers to breaks near the enlarged ends of the tibia and fibula (you can feel these large bony points on either side of your ankle). This area of the bone are known as the ‘malleoli’. Fractures may involve breaks in either malleoli or both together, and in certain serious fractures the talus will be involved. The talus is the first bone of the foot which connects to the leg bones (tibia and fibula).

X-ray showing a fracture of the Fibula.

Ankle fractures are common injuries that are most often caused by your ankle joint rolling inward or outward.

The treatment of an ankle fracture and the time taken to heal will depend on many factors, including:

  • the type of ankle fracture and whether there is dislocation
  • where the bone is broken,
  • how many of the bones are broken
  • the condition of your skin over the fracture.

A common way of classifying fractures is the Weber System. This system is based on the relationship between the two large bones – the fibular and tibia. Just above the ankle joint, these two bones are joined by a strong band of tissue called the ‘syndesmosis’ – a key stabilising feature of the ankle joint.

The first type of ankle fracture, the Weber A, shows breaks in the bones below the syndesmosis. As the syndesmosis is intact and the fibula and tibia are stabilised against each other, Weber A fractures are typically fairly stable and heal well with a simple cast. In contrast, the Weber B and C types will frequently require surgery to stabilise them.

The treatment of your ankle fracture can either be:

  • a simple plaster cast
  • surgery with typically a combination of screws and plates.

Symptoms

Ankle fractures can be extremely painful, though subtle fractures may only be mildly sore. Other features include:

  • Inability to stand on your foot
  • Deformity – the ankle looks twisted or abnormal.
  • Bruising and swelling

Causes

As with many types of fractures, the causes and risk factors can be divided into two types

  • ‘High-energy’ fractures: Large forces on strong bones
    • Ankle fractures are common among sports people who sustain high-speed falls and trauma
    • Other common causes of high-energy fractures are car accidents and falls from large heights 
  • ‘Low-energy’ fractures: Small forces on weak bones
    • In people with weak bones, almost any awkward movement can cause a fracture. Weakness in bones can be due to
    • Osteoporosis
    • Medications and other drugs; most commonly, people who need to take high doses of steroids for long periods of time are at risk of developing weak bones
    • ‘Pathological fractures’ – doctors refer to any condition that weakens a local area of bone , causing it to fracture, as ‘pathological’. This can include any condition from infection to cancer, however these are relatively rare causes of ankle fractures.

Risk Factors

Risk factors for getting an ankle fracture include:

  • Playing high energy or contact sports
  • Having weak bones – this can be caused by osteoporosis, some medications (eg prednisolone or other steroids), advanced age
  • Conditions which make falling more likely – dizziness, advanced age, heart and liver disease, poor nutrition.

How is it diagnosed?

Often, your doctor can diagnose a broken ankle just by looking and feeling, however they will commonly order an X-Ray to confirm the break and look for secondary breaks in the other bones.

When a fracture is subtle, or it involves the soft tissue (ligaments and muscles) around the joint, the doctor may order a CT or MRI scan of the ankle. Unlike an X-Ray, a CTs and MRIs give clear, detailed pictures of the soft tissues.

There are a number of vessels running around the ankle joint that are occasionally damaged. Usually, your doctor will assess any injury to these vessels from looking at and feeling your foot, however occasionally special tests called angiograms are required. Sometimes, a specialist called a vascular surgeon may get involved.Xray of the Ankle showing a severe fracture and dislocation of the Ankle Joint. The tibia has been broken into many parts.

Could I have something other than an ankle fracture?

Conditions that may imitate an ankle fracture include:

  • Ankle sprain : This is an injury to the soft tissues (ligaments and tendons) around the ankle joint.
  • Fracture in the other bones around the ankle, for example the talus or calcaneus

Complications

Are there any complications that I need to be aware of?

General complications after an ankle fracture include:

  • Stiffness of the foot and ankle
  • Pain
  • Swelling
  • Arthritis in later life – One of the most common long term complications affecting your broken ankle is osteoarthritis, or just arthritis. When bones around the joint have broken they are likely to undergo more severe wear and tear than non-injured joints. This causes pain and swelling in the joint and may be severe enough to warrant further treatment.
  • Inadequate healing – the position of the bones in the ankle is very important. For this reason, resetting the bones in the correct position, whether with a plaster or operation, must be exact in order to avoid inadequate healing.

If you require an operation, there are a number of general risks as well as complications specifically associated with ankle repair:

  • Injury to nerves – Numbness or tingling can occur at the wound or in the foot. This is usually temporary but in some it may be permanent.
  • Compartment Syndrome – this occurs when pressure in the foot and ankle, either from swelling or a plaster, cuts off the circulation to the foot. The lack of blood supply causes extreme pain, as well as numbness and/or tingling and can cause longterm damage to the small intrinsic muscles in the foot.
  • Need for further surgery:
    • The metalwork may need to be removed it if becomes prominent or problematic
    • Failure of the bones to heal or incorrect position may result in a salvage operation or arthrodesis.

There are a number of general complications that apply to any surgery. For more information, see Complications of Surgery.

What is the treatment?

This depends upon the type and severity of the injury and is decided by a consultant and their team.

Non-surgical treatment

If the fracture is stable (this means the two ends of the broken bone do not move) and is in a good position it can be treated with a plaster cast below the knee or removable brace. Weight bearing is permitted for stable fractures but not for unstable fractures.

Surgical treatment

If the fracture is very unstable (Weber B/C) or displaced, surgery may be required to reset or “fix” the bones in the correct position. This may involve:

  • Immediate surgery. When the fracture is uncomplicated plates and screws may be used to fix the fracture.
  • Staged surgery. When there has been significant damage to the soft tissues around the joint, the ankle must be rested for a short period of time before surgery can be performed. This allows the swelling and inflammation in the tissues to go down. In the intervening period, the ankle is positioned then held in place by external fixation. While this may be inconvenient and occasionally uncomfortable, the open cage allows the skin and soft tissues to heal. It also allows the medical staff to monitor changes and quickly treat any developing complications, like large bruises or infections. Once the soft tissues are considered safe, surgery will go ahead to fix the joint permanently.

There are variety of different options in the particular operation used, however if surgery is performed you will be non-weight-bearing for at least 2 weeks while the wounds and bones heal.

For many, non-weight-bearing is a frustrating experience. Using crutches or hopping greatly reduces your activities and sometimes ability to return to work. However, it is essential the newly set bones are not over-strained. An in-hospital physiotherapist will assess you for a mobility aid and teach you how to move around, as well as assessing your ability to get up and down stairs.

For more information on the operation, rehabilitation and recovery for ankle fractures see Surgery for Ankle Fractures.

What about pain?

Whilst you are in hospital you will be monitored and the medical staff will give you pain medication as required and prescribed. You will be given instructions on management of the pain by nursing staff before you leave hospital.

Whether you have surgery or not, swelling is quite common. In order to reduce swelling, your foot should be elevated (above the level of your waist) for 50 minutes of every hour for the first two weeks following surgery.

Seeking Advice

Your Family Doctor (GP)

Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to

  • tell you about your problem
  • advise you of the best treatment methods
  • prescribe you medications
  • and if necessary, refer you to Specialists (Consultants) for further treatment

You may initially seek treatment for a broken foot or ankle in an emergency room or urgent-care clinic. If the pieces of broken bone aren’t lined up properly to allow healing with immobilisation, you may be referred to a doctor specialising in orthopaedic surgery.

What you can do

You may want to write a list that includes:

  • Detailed descriptions of your symptoms
  • Information about medical problems you’ve had
  • Information about the medical problems of your parents or siblings
  • All the medications and dietary supplements you take
  • Questions you want to ask the doctor

Prevention

As many ankle fractures are caused by car accidents or sports injuries they cannot be prevented. However, if you have risk factors for osteoporosis (especially women over age 50) you should see your GP for testing and preventative therapy.

F.A.Q. | Frequently Asked Questions

Will I be allowed to weight bear on my leg?

It is important you follow the doctor’s advice regarding whether or not you should be walking or putting any weight through your foot. This advice will be specific to your injury and your treatment (surgery or just a cast).

With some ankle fractures that are relatively minor, you are able to weight bear on your ankle. If this is the case, you will not be placed in plaster but in a special boot and will be able to weight bear as tolerated.

All other types of ankle fractures require being placed in plaster. When you are in plaster you may not take any weight on that leg (see non-weight-bearing). Consequently, you will need crutches or a wheelchair to get around.Your recovery will depend on the type of the fracture and method of treatment.

What should I do if I have a problem?

If you experience severe pain, excessive swelling, inflammation or discharge please report it to your GP. If necessary, go to your local emergency department.

Will I be ok long-term? What should I expect in the future?

Usually, the more complicated unstable fractures are associated with poorer recovery. This is not however a hard and fast rule. In general, you should expect some degree of difficulty with the following aspects of ankle movement:

  • Flexibility
  • Range of movement (ROM) – this term refers to how far you can move your ankle. In the short-term period after the plaster is removed, many people notice they have noticeably limited range. With physiotherapy and time this gradually improves, however subtle limitations may persist long-term. Your surgeon and physiotherapist should be able to give you some idea of what you should expect, however keep in mind that people heal differently and it is impossible to predict precisely how well the return to function will be.
  • Osteoarthritis and other joints – it’s important to remember that the ankle is part of a system involved in walking. This system includes the knee, hip and lower back as well as the other leg, and damage to the one part of the system can affect any other part. This sometimes means that slight deformities in the ankle increase the risk of developing arthritis in the knee, hip or back later in life.

More Information

More information on fractures, relevant treatments and support services can be found at the following sites:

Medical sources on Fifth Metatarsal Fractures:

The latest research on fifth metatarsal fractures is accessible through the Cochrane Library and PubMed Database.

References

McCormack, A. P., Chapter 30: Ankle Fractures, ‘Treatment & Rehabilitation of Fractures’, Hoppenfeld, S., Murthy, V. (Eds), Lippincott Williams and Wilkins, USA, 2000.

Porter, D. A., ‘Functional Outcome after Operative Treatment for Ankle Fractures in Young Athletes: A Retrospective Case Series’, Foot and Ankle International, Vol. 29, No. 9, September 2008, pp 887-894.

Skinner, H. B., ‘Current Diagnosis and Treatment in Orthopaedics’, 4th Ed.

Yufit, P., Seligson D., ‘Malleolar ankle fractures. A guide to evaluation and treatment’, Orthopaedics and Trauma, Vol. 24, Iss. 4, August 2010, pp 286-297.

Wang, R., et al., ‘One year follow-up after operative ankle fractures: A prospective gait analysis study with a multi-segment foot model’, Gait & Posture, Vol. 31, Iss. 2, February 2010, pp 234-240.