Ankle Fracture

An ankle fracture is a fracture affecting the medial or posterior malleolus of the tibia and/or the lateral malleolus of the fibula. There are various types of ankle fractures and the degree of severity of the injury varies, according to the specific characteristics of each fracture.

Ankle Fracture is the consequence of Trauma. This disorder has been reported with an incidence-rate of circa 39 / 100.000.

Presentation

The first step towards a successful diagnosis is a thorough medical history. The patient's routine physical activities, prior ankle injuries are all important clues that will lead the physician to the suspicion of an ankle fracture.  

Ankle fractures usually present with a symptomatology that may resemble that of an ankle sprain. Those two medical entities should be carefully differentiated.

The primary symptoms an individual with an ankle fracture will present with include swelling at the location of the joint, pain, a deformed ankle and inability to walk or exert any type of weight pressure on the affected foot. After careful inspection of the joint, cuts, ecchymoses, and discoloration may be discovered, a finding that is compatible with an ankle injury. A physician should palpate the tibia and fibula in order to detect tenderness and also perform the "squeeze test". The latter involves a simultaneous compression of

Workup

Plain radiographs are a useful tool in order to confirm the diagnoses of an ankle fracture. However, they are solely used in cases of patients meeting any of the following three criteria for a possible ankle fracture [6]:

  • Tenderness of the bone 6 cm distally to the posterior end of the medial malleolus
  • Tenderness of the bone 6 cm distally to the posterior end of the lateral malleolus
  • The patient is unable to exert weight pressure on the affected limb immediately after an injury is sustained. This impairment must continue to be present when the patient is examined.

Anterior, posterior, mortise and lateral views are taken of a patient's foot in order for an accurate diagnosis to be made and a fracture is usually observable on an X-ray [7] [8] [9] [10]. After the fracture has been identified, the stability of the joint must be evaluated, for an appropriate therapeutic plan to be drawn. Palpation of the joint or a simple inspection may reveal instability; the knee joint should also be inspected, in order to assess the degree of stability. An external rotation stress radiograph can additionally be obtained if the aforementioned procedures of inspection and palpation fail to diagnose ligament injury. Depending on the location of the fracture, a computerized tomography scan can help to identify the exact region of traumatization and a magnetic resonance imaging scan can illustrate with accuracy the injury sustained by ligaments or cartilage tissue [11] [12].

Treatment

Treatment options for ankle fractures are both surgical and conservative, depending on the severity of the injury and the stability of the joint. The majority of fractures are treated with reduction, invasive or not, and subsequent immobilization. The patient starts the rehabilitation process either while immobile with simple exercises, or shortly after [13].

The initial treatment of an ankle fracture also depends on the type of fracture. Open fractures, although rare in occurrence, should be definitely protected from contamination; the wound must at all costs be covered with a sterile gauze or cloth to prevent septic phenomena. Fracture reduction is advised only when the ankle is neurologically and vascularly impaired and is discolored, pulseless and pale. 

In general, the first emergency treatment steps towards an ankle injury is a neurovascular evaluation of the joint, splinting in order to immobilize the fractured site, prevent further damage and alleviate pain.

The stability of the joint is pivotal, in order to decide whether a patient should be conservatively  or surgically treated. Fractures that involve the lateral and medial malleolus or the previous two and the posterior side of the tibia  are unstable. Loss of stability is an indication for an open reduction-internal fixation, a surgical procedure required in order to reposition the skeletal parts in their proper position.   

Prognosis

In general, the more severe a fracture is at the time of diagnosis, the more frequently it is accompanied by complications and an unfavorable prognosis. Fractures that are identified early and treated accordingly heal faster and allow for less residual damage, when compared with undiagnosed or mistreated injuries.

Single malleolar fractures typically exhibit an excellent prognosis. Open fractures, if not diagnosed in time, may lead to severe complications such as infection, gangrene, compartment syndrome and vascular damage [5]. Gas gangrene can even fracture. Fractures that affect the joint at the level of the talus may lead to osteoarthritis fracture sustained at the calcaneum may cause an impairment to the inverting and everting movements of the foot.

Etiology

An ankle fracture is sustained when the ankle is subjected to abrupt and violent rotational movements. The majority of the fractures are induced by inverting the ankle joint during intense physical activity.

Epidemiology

Ankle fractures are a type of fracture commonly diagnosed in the clinical practice, displaying an incidence of approximately 180 diagnoses per 100,000 individuals annually [1]. The incidence of the injury exhibits a double peak rate: amongst young, physically active men and amongst the female senior population [2] [3] [4] [5]; this is attributed on the one hand to the intense physical strain a young person may subject their joints to, and, on the other hand, to the osteoporotic degeneration of a female skeleton with the progression of age. Older individuals also tend to sustain an ankle fracture more frequently due to a possible loss of stability. The most common type of ankle fracture is the single malleolar one (65% of all ankle fractures) and the second most commonly diagnosed type is the bimalleolar fracture type. Open fractures are rarely diagnosed. 

Amongst the risk factors for such an ankle injury, smoking and an elevated BMI seems to be the most prominent.

Sex distribution
Age distribution

Pathophysiology

The joint of the ankle comprises four skeletal structures: the tibia, fibula, talus and calcaneus. The tibia and fibula are connected to the latter two structures, which belong to the tarsus group, via two separate ligaments, namely the deltoid ligament (medial), the talofibular ligament (both anterior and posterior) and the calcaneofibular ligament. The ligaments of the region provide stability and a fracture that affects 2 or more of the aforementioned structures, both bones and ligaments, result in the loss of joint stability.

An ankle fracture can be induced either by an extreme inversion or eversion of the foot. Inversion is the most common movement type that leads to ankle fractures. This is attributed to the following two anatomical characteristics of the joint:

  • The deltoid ligament is responsible for the stabilization of the medial side of the joint and is stronger, when compared to the anterior and posterior talofibular ligaments. This results in a greater susceptibility to inversion injuries.
  • The lateral malleolus is longer than the medial malleolus; this leads to an increased ability of the ankle to invert, rather than to evert. 

Transverse fractures are often observed as an indication of an avulsion injury and fractures extending vertically are caused by an impaction to the talus.

Prevention

Wearing proper footwear may help towards the prevention of an ankle fracture. The patient should, after the initial conservative or surgical treatment, be encouraged to resume their daily physical activity routine, in order to strengthen the joint and prevent permanent damage or recurring fractures.

Summary

Ankle fracture (AF) is a type of injury commonly diagnosed in young, active individuals or senior citizens with skeletal degeneration. The traumatization is induced by an abrupt and violent rotation of the ankle in both directions (in- or outward) and can be mild, as in the case of an avulsion injury, or severe, with a bone broken into many pieces. Ligaments may also be injured in some cases.

According to the skeletal part that has sustained the injury, ankle fractures are described as single malleolar, bimalleolar and trimalleolar. A single malleolar fracture is one sustained by the medial malleolus of the tibia or the lateral malleolus of the fibula. On the other hand, a bimalleolar fracture involves both the aforementioned anatomical structures. A trimalleolar fracture affects the lateral malleolus, the medial malleolus and the posterior side of the tibia.

Ankle fractures are further classified with the use of the Danis-Weber classification system, whose criterium is the distance of the injury from the joint of the ankle. There are three Danis-Weber ankle fracture categories:

  • Type A: Avulsion injury located below the level of the talus. It extends horizontally and is a stable injury type if the medial malleolus is not traumatized.
  • Type B: Usually a spiral injury located at the level of the talus and extending at some distance. It may be accompanied by traumatization to the medial malleolus and ligament trauma.
  • Type C: This type of fracture affects the part above the level of the talus. Injury of the ligaments is expected distally to the initial traumatization and surgical intervention is the only option to correct the fracture.

Patient Information

Ankle fractures are a common orthopedic injury affecting the joint of the ankle. 

The specific joint consists of the two bones of the shin, namely the tibia and fibula, as well as of the tarsus bones of the foot and ligaments. An ankle fracture can either affect one of these structures -commonly the tibia or fibula-, or even both of them. In cases where the injury is severer, ligaments are injured as well, and the fibula may be fractured even as high as the level of the knee. 

Ankle fractures are often observed amongst the young population, due to intense physical activity, sports and the general strain their ankle joints are subjected to. The other age group in which these fractures are commonly observed are the women of senior age: osteoporosis and loss of balance are the culprits behind frequently diagnosed ankle fractures. 

A fractured or "broken" ankle, as the injury is commonly referred to, leads to symptoms that range from mild to profound, depending on the severity of the injury and whether ligaments are also involved. A swollen, painful ankle, accompanied by the inability to bear weight on the foot are typical characteristics of a fractured joint. If the injury is severe, the nerves and blood vessels of the adjacent region may also be injured; in this case the pulse of the foot will be absent and the extremity will have assumed a pale color. This is a serious medical emergency.

As far as treatment is concerned, suspected ankle fractures are initially treated with splinting, application of ice, covering of open wounds or, in cases where the nerves and blood vessels seems damaged, a reduction. The process of reduction involves the manual repositioning of the bones in their original position. the injury may then be treated by an orthopedic surgeon either with surgery, or with a cast and immobilization. 

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References

  1. Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone. 2002 Sep;31(3):430-3.
  2. 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.
  3. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand. 1998 Feb;69(1):43-7.
  4. Salai M, Dudkiewicz I, Novikov I, Amit Y, Chechick A. The epidemic of ankle fractures in the elderly--is surgical treatment warranted? Arch Orthop Trauma Surg. 2000;120(9):511-3.
  5. Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. J Orthop Trauma. 1998 Jan. 12(1):67-8.
  6. Dowdall H, Gee M, Brison RJ, Pickett W. Utilization of radiographs for the diagnosis of ankle fractures in Kingston, Ontario, Canada. Acad Emerg Med. 2011 May. 18(5):555-8.
  7. Tandeter HB, Shvartzman P. Acute ankle injuries: clinical decision rules for radiographs. Am Fam Physician. 1997 Jun. 55(8):2721-8.
  8. Schwartz DT, Reisdorff E, Williamson B, eds. Emergency Radiology. New York, NY: McGraw-Hill; 1999.
  9. Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2000 Feb. 18(1):85-113, vi.
  10. Yu JS, Cody ME. A template approach for detecting fractures in adults sustaining low-energy ankle trauma. Emerg Radiol. 2009 Feb 18.
  11. Black EM, Antoci V, Lee JT, Weaver MJ, Johnson AH, Susarla SM, Kwon JY. Role of preoperative computed tomography scans in operative planning for malleolar ankle fractures. Foot Ankle Int. 2013 May;34(5):697-704.
  12. Stäbler A, Szeimies U, Walther M. Stuttgart: Thieme; 2012. Radiologische Diagnostik des Fußes.
  13. Solomon L, Warwick D, Nayagam S. Apley’s concise system of orthopaedics and fractures. 3rd ed London: Hodder Arnold; 2005

  • Accuracy of detection of radiographic abnormalities by junior doctors. - CA Vincent, PA Driscoll, RJ Audley - Archives of emergency , 1988 - emj.bmj.com
  • Changes in bone mass and bone turnover following ankle fracture - BM Ingle, SM Hay, HM Bottjer, R Eastell - Osteoporosis international, 1999 - Springer


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