Sunday, March 03, 2024
Ankle Injuries INJURIES

Broken Ankle- Causes, Symptoms & Treatment of An Ankle Fracture

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A fractured ankle is a break of one of the bones of the ankle. Ankle fractures are serious and should be treated quickly.

Ankle fractures occur in 4.22/10,000 people (1). Broken ankles are more commonly seen in young males (ages 15-24) and women (ages 75-84) (2).

When treating ankle fractures, it’s important to consider what type of fracture the person has, as well as the person’s medical history. 

In this article, we’ll discuss everything you need to know about the management of ankle fractures. 

ankle anatomy

Anatomy of the Ankle Joint (Medial Malleolus, Lateral Malleolus, and Posterior Malleolus)

The ankle joint is a hinged synovial joint. The ankle is made up of three bones: the distal tibia (shin bone), the distal fibula (the bone on the outside of your leg), and the talus (the bone connecting the tibia to the heel bone). 

The “medial malleolus” is the bump on the lower inside portion of your ankle. The “lateral malleolus” is the bump on the lower outside portion of your ankle. 

The “posterior malleolus” is the back portion of the tibia bone above the talus.

The lateral ankle ligaments connect the fibula to the foot. There are also ligaments present on the inside of your ankle called the “deltoid ligament” that connect the tibia to the foot. 

There are syndesmotic ligaments that are present between your tibia and fibula. 

The anatomy of the ankle is important to understand. When ankle injuries happen, disruption of one or more bones/ligaments can occur. Treatment is chosen depending on the extent of the damage.  

twist ankle

What Causes an Ankle Break?

Acute ankle fractures can occur from twisting injuries, falls, motor vehicle accidents, and crush injuries. Anything that places a considerable amount of force on the ankle can cause it to fracture.

Acute ankle fractures are often seen in high-impact sports. However, they can also occur from simply putting your foot and ankle down awkwardly, causing the ankle to crack. 

Wearing certain shoe gear, like high heels, can also increase your likelihood of sustaining a broken ankle.

Stress fractures of the ankle, however, can occur due to gradual repetitive stress in the ankle joint. This can happen from certain activities such as marching, jumping, hopping, or running for very long distances. 

If you have increased your training regimen too fast and too soon, this could increase your chances of sustaining a stress fracture of the ankle. 

ankle sprain symptoms

What Are the Symptoms of a Break in the Ankle?

  • Immediate severe pain in the ankle
  • Swelling of the ankle
  • Bruising of the ankle
  • Ankle deformity from ankle dislocation
  • Inability to bear weight 
  • Discoloration of the skin
  • Tenderness to the touch of the ankle
  • A “pop” or “crack” sound at the time of injury
  • Numbness and tingling 
  • Radiating pain that starts in your ankle and spreads up to your leg and thigh
  • Gradual dull, achy pain that persists with rest (in the case of a stress fracture)

If you suspect that you may have broken your ankle, sit down immediately and ice and elevate your lower extremity. 

RICE therapy should be started immediately. It would be best to avoid eating or drinking anything until you get your ankle evaluated in case you need surgery.

ankle fracture xray

Diagnosis

You should go to the emergency room or your doctor’s office to be evaluated. Your doctor will perform a history and physical exam. Your doctor will want to know your medical history.

Obtaining a thorough medical history is important because factors like diabetes and positive smoking history can impact the healing of a broken ankle. 

Your doctor will order an x-ray to view your ankle. He/she will be checking to see how many bones of the ankle are fractured and if the fractures are displaced (the gap between broken fragments) or non-displaced (broken but in proper alignment). 

Your doctor will also see if there are injuries to the ligaments, and if the fracture extends into the joint.

If there are multiple breaks in the bone, your doctor may want to order a Computed Tomography scan (CT scan). A CT scan can help provide detailed visualization of broken bones and joint. This may be needed for surgical planning. 

A Magnetic Resonance Imaging scan (MRI) may be ordered. This can provide further detail on the fracture as well as identify any ligament/tendon injuries that may also be present. 

If your doctor suspects a stress fracture, they may order a bone scan. During a bone scan, radioactive material would be injected into your vein. This material would accumulate at the fracture site and can help identify/confirm a fracture.

Treatment

Treating ankle breaks will depend on the extent of the injury. Your doctor will be checking if the fracture is nondisplaced or displaced

Another important factor is whether the fracture is comminuted (multiple pieces). 

cast

Nonsurgical Treatment 

If the broken ankle is nondisplaced, your doctor may suggest that you stay off of the limb in a cast or splint for 6-8 weeks minimum to allow for bone healing. 

This would be a good option for someone who sustains a non-displaced stress fracture of the ankle. 

Your doctor will see you every 3-4 weeks after the injury to obtain new radiographs and ensure fracture healing is taking place.

Nonsurgical treatment may also be recommended if someone has extensive health problems such as a history of blood clots, or severe peripheral vascular disease. 

If your doctor believes that you are too high risk to undergo surgery, he/she may recommend nonsurgical treatment. 

fibular fracture repair

Surgical Treatment 

If you sustain a displaced lateral or medial malleolar fracture, your doctor will recommend surgery. If the fracture gap is greater than 2mm or there is shifting of the fracture fragments, your doctor will recommend repairing the broken ankle to ensure the best outcomes. 

The most common type of ankle breaks are unimalleolar fractures of the lateral malleolus of the fibula. Occasionally, a bi malleolus fracture and tri malleolus fracture can occur. Bi means “two”, and Tri means “three”. 

A bimalleolar ankle fracture occurs when there is damage to the medial malleolus of the tibia and the lateral malleolus of the fibula.

A trimalleolar ankle fracture occurs when there is damage to the medial malleolus of the tibia, the lateral malleolus of the fibula, and a fracture of the posterior (back) of the tibia.

The more breaks you have in the ankle, the more unstable the ankle becomes.

Ankle dislocations are often seen with bimalleolar and trimalleolar ankle breaks. 

If your ankle is dislocated, your physician will reduce your ankle dislocation under sedation while in the Emergency room. This will help realign the fracture fragments and can help prevent vascular injury. 

Occasionally, there may be a syndesmosis injury with associated high fibular fracture (Maisonneuve fracture). Syndesmotic injuries should be repaired surgically.

Closed ankle fractures are usually repaired using plates/screws/pins. Open ankle breaks, however, need to be stabilized using an external fixator. 

An external fixator uses rods that attach to the bone and stabilize the fracture using a device outside of the body. 

If you have an open ankle fracture, you will need to be hospitalized and receive IV antibiotics. Your vascular status will need to be assessed to ensure blood vessels were not lacerated during the injury. If they were, they will need to be repaired if at all possible. 

The physician will perform an incision and drainage to clean the fracture and stabilize the fracture fragments using an external fixator. 

Surgery for ankle breaks can be performed by your Podiatrist or Orthopedic Surgeon. Ankle breaks need to be repaired in the operating room under general anesthesia. Surgery can last anywhere from 1-3 hours or more. 

After surgery, the physician will apply a cast or splint on your leg. You will need to remain non-weight bearing in a cast or splint for a minimum of 6-8 weeks. The physician will get radiographs every 3-4 weeks to assess fracture healing. 

Do You Have to Wear a Cast for a Fractured Ankle?

Casts are beneficial in protecting your ankle during the healing process and should be worn the first few weeks after a broken ankle repair.

 Casts can also help keep your ankle in proper alignment during the healing process, and also help reduce swelling in the limb. 

Can You Shower With a Cast On?

You won’t be able to get your leg wet in the shower for several weeks while your leg is in a cast or splint. You can keep your cast covered while in the shower by using a cast bag. You can find this on Amazon. 

After a few weeks, your physician may let you transition into a below-knee boot. The boot can be removed to shower. 

person using crutches while walking in walking boot

Do You Need Crutches With a Walking Boot?

If your doctor wants you to stay off of your lower extremity after a broken ankle, you will need crutches to help you stay off of it. 

However, if you have balance issues or weigh over 300lbs, you should use a knee scooter instead to help you stay non-weightbearing. 

If you are allowed to bear weight, you do not need crutches while using a walking boot. 

Should You Sleep With a Walking Boot?

It’s best to sleep with a walking boot when you are healing from an ankle break. This is because the boot will protect your ankle when you are unknowingly moving around at night. 

You can loosen the bootstraps slightly to help you sleep. Keep your affected leg elevated on pillows while wearing the boot to help reduce swelling. 

How Long Will an Ankle Break Take To Recover?

Ankle breaks can take 6-8 weeks to heal. After your ankle fracture heals, you will need physical therapy for at least a month to regain strength and improve balance. 

Thus, it will take 3 months minimum for you to recover from a broken ankle. Some fractures may take longer than others to heal, especially if they are largely comminuted/displaced. 

Certain factors like smoking can also slow down recovery. 

Can You Walk on an ankle fracture after 4 weeks?

If you have a non-displaced ankle fracture that doesn’t require surgery, like in the case of a hairline stress fracture, your physician may allow you to walk on the broken ankle in a cast boot as long as you can tolerate it. 

Your doctor will be closely monitoring your fracture with x-rays every 3-4 weeks to make sure the fracture is healing. 

What Are the Long-Term Effects of an ankle fracture?

High-impact ankle fractures that extend into the joint can cause long-term complications such as arthritis, stiffness, and even nerve pain. You may notice occasional pain or discomfort while performing your activities. Pain may be worse the longer you are on your feet.

Ankle dislocation
Ankle dislocation

What Happens if a Broken Ankle Is Untreated?

If you have a broken ankle that is left untreated, you may develop permanent deformity and damage to the ankle. If you walk on a displaced foot fracture/ankle fracture, the fracture can worsen. 

You may develop delayed healing of the fracture site or non-union. A non-union is a fracture that doesn’t heal. Non-unions can be painful. 

How Long Does the Pain Last With a Broken Ankle?

Pain from an ankle fracture can be present until the fractured bones are healed. This can take 6-8 weeks minimum. However, pain may be present for months due to arthritis and nerve injury that can occur at the time of injury. Your doctor will help you manage your pain with pain medications and physical therapy. 

pain in ankle

Conclusion

In conclusion, this article provides a comprehensive overview of ankle fractures, including their causes, symptoms, and treatment options. Ankle fractures can result from various traumatic incidents and high-impact activities, causing immediate pain, swelling, and deformity. The anatomy of the ankle joint, specifically the medial and lateral malleoli, is discussed, along with the ligaments and bones involved. Treatment approaches are determined based on factors such as fracture displacement, comminution, and individual medical history.

 Nonsurgical options, including immobilization in casts or splints, may be suitable for non-displaced fractures, while surgical intervention, such as the use of plates, screws, or external fixators, is recommended for displaced fractures, including bimalleolar and trimalleolar fractures. 

The importance of prompt medical diagnosis, comprehensive evaluation, and monitoring through diagnostic imaging techniques like X-rays, CT scans, and MRIs is emphasized. Additionally, the article addresses post-treatment considerations, such as the use of casts, showering restrictions, the need for crutches or walking boots, and the duration of recovery. Long-term effects of ankle fractures, such as arthritis and stiffness, are highlighted, underscoring the significance of appropriate treatment and follow-up care provided by Orthopaedic/Podiatric specialists. 

By reviewing the symptoms, types of fractures, treatment options, and overall impact on health and well-being, this article serves as a valuable resource for individuals seeking information about ankle fractures in the field of medicine.

A Supplemental article:

Everything You Need To Know About Foot Stress Fractures

Ankle Arthroscopy: Ankle Surgery & Recovery (A Simple Guide)

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ankle fracture pin

References

  1. Scheer RC, Newman JM, Zhou JJ, Oommen AJ, Naziri Q, Shah NV, Pascal SC, Penny GS, McKean JM, Tsai J, Uribe JA. Ankle Fracture Epidemiology in the United States: Patient-Related Trends and Mechanisms of Injury. J Foot Ankle Surg. 2020 May-Jun;59(3):479-483.https://pubmed.ncbi.nlm.nih.gov/32354504/
  2. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures–an increasing problem? Acta Orthop Scand. 1998 Feb;69(1):43-7.https://pubmed.ncbi.nlm.nih.gov/9524517/
  3. Wire J, Hermena S, Slane VH. Ankle Fractures. 2022 May 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.https://pubmed.ncbi.nlm.nih.gov/31194464/
  4. Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014 May 23;111(21):377-88.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075279/
  5. Kyriacou H, Mostafa AMHAM, Davies BM, Khan WS. Principles and guidelines in the management of ankle fractures in adults. Journal of Perioperative Practice. 2021;31(11):427-434.https://journals.sagepub.com/doi/full/10.1177/1750458920969029
  6. Ovaska, M. (2015). Complications in ankle fracture surgery. Acta Orthopaedica, 86(sup358), 1-35.https://www.tandfonline.com/doi/full/10.3109/17453674.2014.1002273
  7. Egol, K. A., Tejwani, N. C., Walsh, M. G., Capla, E. L., & Koval, K. J. (2006). Predictors of short-term functional outcome following ankle fracture surgery. JBJS, 88(5), 974-979.https://journals.lww.com/jbjsjournal/Abstract/2006/05000/Predictors_of_Short_Term_Functional_Outcome.7.aspx
  8. Koval, K. J., Zhou, W., Sparks, M. J., Cantu, R. V., Hecht, P., & Lurie, J. (2007). Complications after ankle fracture in elderly patients. Foot & ankle international, 28(12), 1249-1255.https://journals.sagepub.com/doi/abs/10.3113/fai.2007.1249
  9. Hancock, M. J., Herbert, R. D., & Stewart, M. (2005). Prediction of outcome after ankle fracture. Journal of Orthopaedic & Sports Physical Therapy, 35(12), 786-792.https://www.jospt.org/doi/abs/10.2519/jospt.2005.35.12.786

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Vaishnavi Bawa
Dr. Vaishnavi Bawa is a Podiatrist who specializes in treating foot and ankle pathology. LifesLittleSteps mission is to educate the public about foot health in an easy-to-understand manner using evidence-based medicine.
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