There is a popular saying that one would rather break a bone than tear a ligament… and there is some truth to this.

Soft tissue injuries to the foot and ankle can be mild and have a relatively rapid and straightforward recovery while other more severe soft tissue injuries can lead to lingering long-term issues such as chronic ankle weakness, instability, pain, swelling and eventually to degradation of the joint. Inversion ankle injuries (ankle sprains) are perhaps the most common presenting injury at your local ER or urgent care facilities, yet many times if no fractures are seen on x-ray, the patient is told the “good news” that it is just a sprain or strain and sent home with some basic information on sprains. However, this can be misleading as ligament tears, cracked cartilage, and tendon ruptures cannot be diagnosed on x-rays alone.

This is where a highly trained foot and ankle specialist can make a big difference with a thorough workup and physical examination of your ankle to check strength and stability and in many cases order an MRI to rule out more severe injuries such as bone contusions (bruising), cartilage damage, and ligament or tendon tears/ruptures. Proper diagnosis is key to minimizing any long-term problems associated with these injuries as some soft-tissue injuries heal better (and faster) with early surgical intervention.

Stress Fracture Diagnosis?

Stress fractures are usually not seen on initial x-rays, but may show up over several weeks with an increased amount of bone formation as the bone heals. Sometimes an MRI or a bone scan may be necessary to confirm the diagnosis.

Stress fracture treatment options

Foot and ankle stress fractures are treated with non-weight bearing to the affected area, and may require crutches and a cast or cast boot until the bone heals. Often, a bone stimulator which is a non-painful machine that speeds up healing is used.

After the bone is healed, an orthotic or custom insole may be used to decrease the pressure on the fracture region and allow uniform pressure distribution across the foot and ankle.

What Causes an Ankle Fracture?

Fractures of the ankle, also called a broken ankle are commonly the result of an inversion ankle rotational or rolling injury; much like how the ankle rolls when it's sprained. A high impact injury, as in a car accident or fall, can also result in an ankle fracture. A fracture is a partial or complete break in a bone. In the ankle, fractures involve the far or distal ends of the tibia, the fibula, or both bones. The tibia is the shinbone and is located on the inner, or medial, side of the leg. The fibula is located on the outer, or lateral, side of the leg. The distal ends of the tibia and fibula bones are also known as the medial and lateral malleoli, respectively.

Some distal tibia fractures can involve the rear or posterior part of the bone, which are also known as posterior malleolar fractures. Ankle fractures can range from the less serious avulsion injuries (small pieces of bone that have been pulled off) to severe, shattering-type breaks. Some fractures may also involve injuries to important ankle ligaments that keep the ankle in its normal position. Ankle fractures are commonly caused by the ankle twisting inward or outward.

Brief Overview of Treatments for an Ankle Fracture 

Treatment options for a broken ankle differ depending on the severity of the injury. If the broken bones are not out of place and the ankle is stable, the injury can usually be treated without surgery. These treatment options include: walking boot, cast or removable brace and the use of crutches or a knee roller/scooter.

However, if the ankle is unstable, broken in more than one place, or the fracture is out of place, surgery may be required align the joint in the correct position and prevent future problems associated with an ankle fracture that doesn’t heal properly which can lead to several long terms issues including instability, chronic pain, residual deformity and the development of debilitating arthritis of the ankle joint.

Symptoms an Ankle Fracture

One or all of these signs and symptoms may accompany an ankle fracture:

• Pain: Typically located at the site of the fracture, but can radiate from the foot to the knee.
• Swelling and Bruising: May occur along the length of the leg or be more localized at the ankle. Swelling can be so severe a times that the skin may even blister. Blisters may occur over the fractured area.
• Inability Place Weight on Foot/Ankle: It is possible to walk or bear weight upon the ankle with less severe fractures. Never rely on walking as a test of whether the ankle is fractured.
• Deformity and Dislocation: Following an ankle fracture, the foot may be turned in an awkward position. This is an indication that there has been a severe injury to the bones leading to stability. This is considered an emergency. Please make sure you go to either your foot and ankle specialist or to the emergency room in order to obtain a rapid diagnosis and reduction. The longer an ankle is out of position, the more likely there will be an adverse effect on the potential healing as the vascularity to the ankle can also be disrupted. In extreme cases, the fractured bones may protrude through the skin. This condition is known as an open ankle fracture. These types of ankle fractures require immediate treatment to avoid problems like infection.

How are Ankle Fractures Diagnosed?

Most patients with ankle fractures are treated in an emergency room or a doctor’s office. An X-ray of the damaged ankle may be taken to determine what the fracture looks like, which bones are broken, how separated or displaced the bones are, and to find out the condition of the bone itself. The X-ray will help determine the proper course of treatment. In some cases, a CT scan may be helpful to help determine the extent of the fracture, especially if there are more than two fractures on to diagnose a fracture that extends into the ankle joint.

Ankle Fracture Treatments

Conservative Treatment

Ankle fractures that don’t have gapping or angulations/rotation at the fracture site are usually treated with cast and if indicated, physical therapy. These usually do not require surgery. 

• Elevation and Ice: Swelling is often seen after an ankle fracture. By limiting the amount of swelling, the pain from the ankle fracture can be decreased and further damage to the surrounding soft tissue may be prevented. Elevating the ankle and icing the affected area can help to limit swelling.
• Splint: A splint may need to be placed to support the broken ankle. The splint usually remains for several days. A splint allows for room to accommodate swelling. If the damaged ankle is not displaced, the splint may be applied immediately without moving the broken ankle. However, if the bones are displaced and/or the ankle joint is dislocated, a closed reduction is performed while the splint is placed. This treatment involves setting the tibia and/or fibula bones and ankle joint to improve the position and pain at the ankle. This treatment may require some type of anesthesia.
• Rest/No Weight Bearing: Most patients require some period of rest with no weight being put upon the ankle. Crutches, walkers, knee rollers and wheelchairs allow patients to keep weight off of the ankle. Many factors can determine which is the best choice for an individual patient. The type of ankle fracture will determine when patients can start to stand and walk on their injured ankle. In many cases, a patient will not be able to place any weight on the ankle for several days, weeks or even months. This is a determination that must be made by your foot and ankle specialist.
• Cast/Fracture Boot Immobilization: Some ankle fractures can be treated without surgery. These are usually injuries where one bone is minimally displaced. Such fractures can be treated simply with a period of immobilization. Once the initial swelling improves over the first several days, either a cast or a fracture boot can be applied to the ankle to properly protect and immobilize it. Both a cast and a boot can provide adequate protection to the ankle. A cast cannot get wet or be removed without special tools. A boot can be removed for bathing and sleeping. The type of fracture and the physician’s judgment will determine the best type of immobilization. The cast or boot is worn until the fracture is fully healed, which usually takes two to three months.

Surgical Treatment

Ankle fractures often require surgery to replace the fractured pieces to normal anatomic alignment and put the ankle joint in the correct position. The surgical treatment is known as an open reduction and internal fixation or ORIF. This is usually accomplished with the help of specially designed plates and screws. There are several reasons why an ankle fracture will require surgery. If the fracture is displaced or angulated, and the ankle joint is no longer aligned, surgery is required to realign the ankle joint. It is essential to align the ankle fracture to within 2 millimeters of original position for optimal long-term results. Ankle fractures involving joint cartilage can lead to arthritis in the joint. It is especially important that ankle fractures are reduced to return the anatomy to its normal position and alignment. 

Ankle fractures will also require surgery if the ankle is broken in several places (called a bi-malleolar or tri-malleolar fracture). These types of ankle fractures are very unstable, and will require surgery to stabilize the joint. If these injuries are not stabilized with surgery, the bones will likely shift, causing a malalignment of the joint, which may lead to post-traumatic arthritis in the ankle.

As the ankle heals after surgery, the joint is protected with restricted activity and a cast or fracture boot. The cast or boot is worn until the fracture is fully healed, which usually takes two to three months.

 

Rearfoot fractures of either the heel bone (calcaneus) typically occur after a high impact/velocity injury, such as a fall from height or motor vehicle accident. Due to the force of the injury, the damage is often extensive and often requires surgery. These injuries are also closely associated with the development of post-traumatic arthritis of the subtalar joint (rearfoot).

Causes of a Calcaneal Fracture

A calcaneal fracture occurs when an excessive force crushes the heel bone against the talus (the lowest bone of the ankle). The joint between the calcaneus and the talus is known as the subtalar joint, and it is an essential biomechanical component of flexing, standing, and walking and couples with the ankle joint for dynamic motion. This joint is often involved in these types of facture which can lead to long term problems with the joint such as chronic pain, stiffness and the development of arthritis.

Treating a calcaneal fracture can be extremely tricky, because the fracture is rarely a clean break like you might see in a broken shin or arm. Think of the calcaneus as an egg… with in intact shell it is hard to break when you squeeze it in the palm of your hand, however, if there is any defect or crack in the surface, any abnormal pressure to the shell cause it to crumble as the center is soft and sponge-like. When the calcaneus fractures, the hard outer layer can break into multiple irregular fragments and fold in on itself, just like an egg with a broken shell.

Types of Calcaneal Fractures

There are several types of fracture patterns that can occur with trauma to the heel bone. Some have more simple patterns that do not involve the joint and usually heal without any long term issues while others are more complex with fragment displacement and extend into one of multiple joints and are very challenging to get to heal properly, often requiring surgical intervention to optimize healing.

• Intra-articular fractures. These involve damage to the cartilage between the joints, and are considered the most serious type of heel fracture. These have a high correlation with the eventual development of post traumatic arthritis of the involved joint (s)
• Avulsion fractures. A fragment of bone is avulsed away from the calcaneus from the pulling from the Achilles tendon or another ligament.
• Multiple fracture fragments. This is also known as a crushed heel injury and is more common with higher impact injuries such as a fall from height or automotive accident.
• Stress fractures. While most calcaneal fractures are caused by a trauma, a calcaneal stress fracture can result from overuse or repetitive trauma (like high volume running or jumping).

Symptoms of a Calcaneal Fracture

• Sharp, severe pain
• Extensive swelling and bruising in the heel region
• Inability to bear weight
• A general pain in the heel that gradually worsens could be a sign of a stress fracture. This will typically on hurt during activity and gets better with rest.

Diagnosing Calcaneal Fractures

If you have recently experienced a trauma and are experiencing symptoms of a calcaneal fracture, visit your foot and ankle specialist. You doctor will evaluate your foot for swelling and other signs of a fracture or joint damage. X-ray imaging can be helpful in making a diagnosis. Your doctor may also order a CT scan to get a better idea of the pattern of the fracture, to determine whether surgery is needed.

Depending on the cause of your injury, your foot and ankle specialist may also examine you for an ankle or mid-foot injury, or refer you to another specialist to check for injuries beyond the foot. About 10% of patients with calcaneal fractures also suffer a back injury called a Lumbar spinal burst fracture. This occurs when a vertebra in the lower-mid back is crushed. Please let you doctor know if you are also experiencing any back pain.

Calcaneal Fracture Treatment

Heel bone fractures are notoriously difficult to treat, and usually require prolonged healing times. Your foot and ankle specialist will assess your injury and determine whether to treat the fracture surgically or non-surgically.

Conservative Treatment

Conservative treatment is most appropriate for simple, non-displaced fracture patterns, especially if they do not involve the joint. A conservative, non-invasive treatment regimen may also be recommended for patients who are not good candidates for surgery. Smokers, elderly patients, and patients with diabetes or vascular disease may be at higher risk for surgical complication, such as an infection or blood loss.

As severe as calcaneal fractures can be, studies have shown that non-surgical treatment can be very nearly as effective as surgical treatment in the right individuals. Typically, non-surgical treatment involves:

• Non-weight bearing status for up to 10-12 weeks
• Immobilization in a cast, fracture boot or splint for 8-10 weeks
• Elevation of the foot. When resting, prop your foot up on stools or pillows to keep it above your heart.
• Icing. Apply malleable freezer gel packs to the anterior ankle. Change every 2-3 hours to help with swelling
• Compression. Wrap your heel in a compression sock or ace bandage.
• Pain medication. Your doctor may prescribe you pain medication or you can take over-the-counter NSAIDs, such as Ibuprofen and Naproxen. Please note that narcotics in our practice are extremely restricted and are NOT a good long term solution.
• Physical therapy exercises. After 2 weeks, practice drawing a figure-8 with the toes to increase your range of motion in the ankle.

Surgical Treatment

• Open Surgical Approach: Surgical correction of a calcaneal fracture takes an extremely skilled surgeon, and is inherently risky. Your surgeon will reconstruct the heel bone to something close to its original shape. Because each fracture is different, each surgical procedure is highly individualized.
  
  Typically, surgery cannot begin until the swelling has gone down, about 10-14 days following the trauma. Operating on an excessively swollen foot may lead to healing problems and it can increase the risk for infection.
  
  The surgery is generally performed through an open incision on the outer side of the heel. The surgeon then carefully repositions the fragments and fixes them into place with anatomically designed screws and plates.
  
  

• Percutaneous Approach: This is a minimally-invasive surgical technique that can be performed on some less complex fractures (less than 10%). The surgeon makes a small incision and pierces the pieces of fractured bone with surgical wire. The surgeon can then manipulate the pieces into place. Once the fragment position is optimized, then a plate can be slid under the skin and fixated to the bone with a few screws placed through minute incisions along the periphery of the plate or with multiple screws placed strategically around the fracture without a plate.

Complications of Calcaneal Fracture Surgery

Surgical correction of a fractured heel bone is a risky procedure. Common complications may include:

• Infection. Unfortunately, these can occur. In mild cases, this may be treated with oral antibiotics. In more severe cases, the entire surgical may become compromised and require a removal of hardware and any infected tissue or bone. Osteomylelitis is a severe deep-wound infection that affects the bone, and the calcaneus is particularly vulnerable following this type of injury. If this occurs, this may require multiple surgeries in order to resolve the infection, long term use of IV antibiotics, and in some extreme cases can lead to limb loss if the infection becomes a threat to your health.
• Would healing problems. Because circulation to the heel’s soft tissues is relatively weak, the surgical site may not heal properly and may require additional wound care and/or skin grafting.
• Subtalar arthritis. This is a chronic pain condition which commonly affects patients with healed calcaneal fractures. If this occurs, at some point you may need to undergo an additional procedure to fuse the affected joints which most commonly the subtalar joint.
• Nerve damage. You may experience permanent numbness at the surgical site. In some cases, the sural nerve (which runs through in incision site) may become entrapped in scar tissue and can become quite painful.
• Non-union: Sometimes the bone simply doesn’t heel. If this is the case, the use of a bone growth stimulator (non-invasive) may be beneficial. In more severe cases, this may require additional surgery to help the bone resume normal healing.

Recovery from Calcaneal Fracture Surgery

Following surgery, your foot and ankle specialist will likely immobilize your foot in a splint to allow the bone and joints time to heal. You should follow the at-home treatments recommended for non-surgical patients, including rest, ice, elevation, and compression.

You should avoid bearing weight on the foot for 10-12 weeks until it is sufficiently healed. This is often determined by serial x-rays performed in the office during your follow-up visits. Once you are allowed to bear weight on the foot, Dr. Perler usually sends you for physical therapy who will help you get back to full weight bearing and out of the boot over the following month. Also, many patients will benefit from either custom or over the counter arch supports.