> Table of Contents > Ankle Fractures
Ankle Fractures
Wendy Hin-Wing Wong, MD, MPH
Jeffrey P. Feden, MD, FACEP
image BASICS
  • Bones: tibia, fibula, talus
  • Mortise: tibial plafond, medial and lateral malleolus
  • Ligaments: syndesmotic, lateral collateral, and medial collateral (deltoid) ligament
DESCRIPTION
  • Two common classification systems help describe fractures (but do not always predict fracture stability)
    • Danis-Weber system: based on level of the fibular fracture in relationship to the syndesmosis
      • Type A: below syndesmosis (of tibiofibular joint). Usually stable (30% of ankle fractures)
      • Type B (most common): at syndesmosis. Can be stable or unstable (63%)
      • Type C: above syndesmosis. Usually unstable (7%)
    • Lauge-Hansen (LH): based on foot position and direction of applied force relative to the tibia
      • Supination-adduction (SA)
      • Supination-external rotation (SER): most common, 40-75% of fractures
      • Pronation-abduction (PA)
      • Pronation-external rotation (PER)
  • Stability-based classification
    • Stable
      • Isolated lateral malleolar fractures (Weber A/B) without talar shift and with negative stress test
      • Isolated nondisplaced medial malleolar fractures
    • Unstable
      • Bi- or trimalleolar fractures
      • High fibular fractures (Weber C) or lateral malleolar fracture with medial injury and positive stress test
      • Lateral malleolar fracture with talar shift/tilt (bimalleolar equivalent)
      • Displaced medial malleolar fractures
  • Pilon fracture: tibial plafond fracture due to axial loading (unstable)
  • Maisonneuve: fracture of proximal 1/3 of fibula associated with ankle fracture (unstable); high risk of peroneal nerve injury
Pediatric Considerations
  • Ankle fractures are more common than sprains in children compared to adults because ligaments are stronger than physis.
  • Talar dome: osteochondral fracture of talar dome; suspect in child with nonhealing ankle “sprain” or recurrent effusions
  • Tillaux: isolated Salter-Harris III of distal tibia with growth plate involvement
  • Triplane fracture: Salter-Harris IV with fracture lines oriented in multiple planes: 2-, 3-, and 4-part variants
EPIDEMIOLOGY
  • Ankle fractures are responsible for 9% of all adult and 5% of all pediatric fractures
  • Peak incidence: females 45 to 64 years; males 8 to 15 years. Average is 46 years.
Incidence
  • 107 to 184 per 100,000 people per year
  • 3-fold increase in incidence predicted 2000 to 2030 in adults >60 years old
ETIOLOGY AND PATHOPHYSIOLOGY
  • Most common: falls (38%), inversion injury (32%), sports-related (10%)
  • Plantar flexion (joint less stable in this position)
  • Axial loading: tibial plafond or pilon fracture
RISK FACTORS
  • Age, fall, fracture history, polypharmacy, intoxication
  • Obesity, sedentary lifestyle
  • Sports, physical activity
  • History of smoking or diabetes
  • Alcohol or slippery surfaces
GENERAL PREVENTION
  • Nonslip, flat, protective shoes
  • Fall precautions in elderly
COMMONLY ASSOCIATED CONDITIONS
  • Most ankle fractures are isolated injuries, but 5% have associated fractures, usually in ipsilateral lower limb.
  • Ligamentous or cartilage injury (sprains)
  • Ankle or subtalar dislocation
  • Other axial loading or shearing injuries (i.e., vertebral compression or contralateral pelvic fractures)
image DIAGNOSIS
PHYSICAL EXAM
  • Examine skin integrity (open vs. closed fracture).
  • Assess point of maximal tenderness.
  • Assess neurovascular status, pulses, motor/sensory exam, and ability to bear weight.
  • Evaluate for compartment syndrome.
  • Consider associated injuries (secondary survey).
  • Assess ankle stability: anterior drawer test for the anterior talofibular ligament (ATFL), talar tilt test for lateral and medial ligaments, squeeze test and external rotation stress test for the tibiofibular syndesmosis
DIFFERENTIAL DIAGNOSIS
  • Ankle sprain
  • Other fractures: talus, 5th metatarsal, calcaneus
DIAGNOSTIC TESTS & INTERPRETATION
  • Plain films: first line for suspected fractures (1)[A]
  • Ottawa Ankle Rules (OAR): Overall sensitivity of 98% in adults, increases to 99.6% if applied within the first 48 hours after trauma (2)[A].
  • OAR suggest films in patients aged 18 to 55 years if:
    • Tenderness at the posterior edge or tip of the medial malleolus, OR
    • Tenderness at the posterior edge or tip of the lateral malleolus, OR
    • Inability to bear weight both immediately and in the ED for four steps, OR
    • Tenderness at navicular or 5th metatarsal (Ottawa Foot Rules)
  • If symptoms persist past 48 to 72 hours, obtain x-rays.
  • In children > 1 year old, OAR sensitivity is 98.5%.
  • OAR not valid for intoxicated patients, those with multiple injuries, or sensory deficits (neuropathy)
  • Three standard views
    • Anteroposterior (AP)
    • Lateral: talar dome/distal tibia incongruity indicate instability
    • Mortise (15- to 25-degree internal rotation view): symmetry of mortise; space between the medial malleolus and talus should be ≤4 mm
    • Additional stress view may demonstrate instability: increased medial clear space with manual external rotation
Pediatric Considerations
  • Consider tenderness over distal fibula with normal films as Salter-Harris I.
  • Stress views unnecessary in children and may cause physeal damage (3)[C].
  • Salter-Harris V often missed, diagnosed when leg length discrepancy or angular deformity after Salter-Harris I; rare, 1% of fractures (3)[C]
Follow-Up Tests & Special Considerations
  • CT recommended for operative planning in trimalleolar, Tillaux, triplane, pilon fractures, or fractures with intra-articular involvement (1)[A].
  • MRI not routinely indicated; does not increase sensitivity for detecting complex ankle fractures (4)[C]
    • MRI useful for chronic instability, osteochondral lesions, occult fractures, and unexpected stiffness in children
Diagnostic Procedures/Other
  • Ultrasound for soft tissue injury associated with displaced fractures (1)[A]
  • Bone scan or MRI for stress fracture
image TREATMENT
GENERAL MEASURES
  • Immobilize in temporary cast/splint and protect with crutches/nonweight bearing
    • 1 to 2 weeks to allow decreased swelling, if not open or irreducible fracture (5)[C]
  • Ice and elevate the extremity; pain due to swelling best controlled with elevation (6)[A]
    • Compression stockings offer no benefit for swelling (7)[A].
  • Closed ankle fractures: stable versus unstable
    • Stable = nonoperative (1)[A]
    • Unstable = surgery
    • Lateral shift of talus ≥2 mm or displacement of either malleolus by 2 to 3 mm = surgery (5)[C]
    • In adults with displaced fractures: insufficient evidence if surgery or nonoperative management produces superior long-term outcomes (8)[A]
  • Stable syndesmosis injury = nonoperative
  • Fracture dislocations: urgent reduction
    • Do not wait for imaging if neurovascular compromise or obvious deformity.
    • Flex hip and knee 90 degrees for easier reduction.
    • Post reduction: neurovascular exam and x-rays
MEDICATION
First Line
  • NSAIDs and/or acetaminophen for pain (1)[A]
  • Initial IM pain injection (i.e., Ketorolac, ≥50 kg adult: 60 mg or 30 mg q6h, max 120 mg daily; children 2 to 16 years old, <50 kg or ≥ age 65 years: 1 mg/kg, 30 mg, or 15 mg q6h, max 60 mg daily) (6)[A]
  • P.57

  • For suspected open fractures: tetanus booster, broad-spectrum cephalosporin and aminoglycoside within 3 hours post injury (5)[C]
  • Intra-articular or hematoma block (1)[A]
Second Line
Opioid analgesics as adjunctive therapy (1)[A]
ISSUES FOR REFERRAL
  • Consultation for neurovascular compromise, tenting of skin or open fracture, displaced or unstable fracture, compartment syndrome
  • All other fractures: follow-up within 1 week and remain nonweight bearing. Consult orthopedics if not comfortable with routine fracture management.
ADDITIONAL THERAPIES
  • Nonoperative = cast immobilization
    • No difference in type of immobilization (air-stirrup, cast, orthosis) (7)[A]
    • Initially nonweight bearing with crutches, then advance to 50% with crutches. Full weight bearing after 6 weeks post injury (6)[A]
    • If removable cast, gentle range of motion exercises at 4 weeks (6)[A]
  • Open ankle fractures (2%)
    • Remove gross debris/contamination in ED.
    • Duration of optimal antibiotic therapy controversial
    • Surgical emergency, best if repaired within 24 hours
SURGERY/OTHER PROCEDURES
  • Surgical options
    • Open reduction internal fixation (ORIF); preferred in athletes and unstable fractures
    • External fixation may be preferred in extreme tissue injury or comminuted fractures; may have more malunion compared to ORIF, but no difference in wound complications
  • Timing of surgery
    • Immediately if neurovascular compromise, open fracture, unsuccessful reduction, tissue necrosis (5)[C]
    • Otherwise delay > 5 days post injury because inflammation can affect wound healing (5)[C].
  • Length of recovery: usually 6 to 8 weeks
Pediatric Considerations
  • Salter-Harris I and II = nonoperative
    • Distal tibia: long leg cast for 4 to 6 weeks, then short leg cast for 2 to 3 weeks (4)[C]
    • Distal fibula: posterior splint or ankle brace 3 to 4 weeks, weight bearing. If displaced, then short leg cast 4 to 6 weeks, nonweight bearing (4)[C]
    • Limit reduction attempts because of potential injury to growth plate (3,4)[C].
    • Reduction not recommended if presenting ≥ 1 week post injury (4)[C]
    • Intra-articular displacement of ≥ 2 mm in child with > 2 years growth remaining = ORIF (3)[C]
  • Salter-Harris III and IV:
    • Distal tibia: if > 2 mm displacement = ORIF (3)[C]
    • Distal fibula: rare, usually stable after tibial reduction (3)[C]
    • Tillaux and triplane: ORIF if displaced ≥2 mm (3,4)[C]
Geriatric Considerations
  • Higher surgical risk due to age/comorbidities
  • Osteoporosis increases risk of implant/fixation failure (8)[A].
  • Risks from surgery/anesthesia: wound healing problems, pulmonary embolism, mortality, amputation, reoperation
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Admit if:
  • Emergency surgery required
  • Patient nonadherent, lacks social support, unable to maintain non-weight-bearing status or has significant associated injuries
  • Concerning mechanism of injury (i.e., syncope, myocardial infarction, head injury)
Nursing
Nonweight bearing, maintain splint/cast, apply ice, keep leg elevated, pain control, assist in ADLs
Discharge Criteria
  • Ambulates with walker or crutches
  • Medical workup (if needed) completed
  • Orthopedic follow-up arranged
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Orthopedic follow-up: serial x-rays
    • In children, sclerotic lines on x-ray (Parker-Harris growth arrest lines) indicate growth disturbance (4)[C].
  • Immobilize for 4 to 6 weeks, then progressive activity, weight bearing, with removable splint or boot (7)[A]
  • Physical therapy referral: no difference in outcomes between stretching, manual therapy, exercise program (7)[A]
DIET
NPO if surgery is being considered.
PATIENT EDUCATION
  • Ice and elevate for 2 to 3 weeks, use crutches/cane as instructed, splint/cast care (avoid getting wet, etc.)
  • Notify physician if swelling increases, paresthesias, pain, or change in color of extremity
PROGNOSIS
  • Good results can be achieved without surgery if fracture is stable.
    • Most return to activity within 3 to 4 months
  • Most athletes return to preinjury activity levels.
  • Increasing age, NOT injury severity, associated with worsening mobility after fracture (9)[B]
REFERENCES
1. Ankle and foot disorders. In: Hegmann KT, ed. Occupational Medicine Practice Guidelines. Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011:1-268. http://www.guideline.gov/content.aspx?id=36625&search=%22ankle+fractures%22. Accessed June 9, 2015.
2. Polzer H, Kanz KG, Prall WC, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012;4(1):e5.
3. Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001;9(4):268-278.
4. Parrino A, Lee MC. Ankle fractures in children. Curr Orthop Pract. 2013;24:617-624.
5. Mandi DM. Ankle fractures. Clin Podiatr Med Surg. 2012;29(2):155-186.
6. Work Loss Data Institute. Ankle & Foot (Acute & Chronic). Encinitas, CA: Work Loss Data Institute; 2013. http://www.guideline.gov/content.aspx?id=47571&search=ankle+fracture. Accessed June 18, 2015.
7. Lin CW, Donker NA, Refshauge KM, et al. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012;(11):CD005595.
8. Donken CC, Al-Khateeb H, Verhofstad MH, et al. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev. 2012;(8):CD008470.
9. Keene D, James G, Lamb SE, et al. Factors associated with mobility outcomes in older people post-ankle fracture: an observational cohort study focusing on peripheral vessel function. Injury. 2013;44(7):987-993.
Codes
ICD10
  • S82.899A Oth fracture of unsp lower leg, init for clos fx
  • S82.899B Oth fracture of unsp lower leg, init for opn fx type I/2
  • S82.56XA Nondisp fx of medial malleolus of unsp tibia, init
Clinical Pearls
  • OAR are nearly 100% sensitive in determining the need for x-rays.
  • Assess neurovascular status, ability to bear weight, associated injuries.
  • Assess joint above (Maisonneuve).
  • Normal x-rays with point tenderness indicate Salter-Harris type I fractures in children.