Ankle Fractures (Broken 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.