Ankle fracture

This page is for adult patients. For pediatric patients, see: ankle fracture (peds)

Clinical Features

• Examine for ecchymoses, abrasions, or swelling
• Vascular and neurologic assessment
  • DP and PT pulses
  • 4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
• Note skin integrity and areas of tenderness or crepitus over ankle
• Range joint passively and actively to evaluate for stability
• Examine joints above and below the ankle
• Perform anterior drawer test (positive exam suggests torn ATFL)
• Always palpate entire length of fibula to rule-out Maisonneuve Fracture (fibulotibialis ligament tear)
  • Perform a crossed-leg test to detect syndesmotic injury
• Evaluate integrity of Achilles tendon (Thompson test)
• Palpate midfoot and base of 5th metatarsal for tenderness

Differential Diagnosis

Other Ankle Injuries

• Ankle sprain
• Ankle dislocation
• Ankle syndesmosis injury
• Radiograph-negative ankle injury (peds)

Distal Leg Fracture Types

• Tibial plateau fracture
• Tibial shaft fracture
• Pilon fracture
• Maisonneuve fracture
• Tibia fracture (peds)
• Ankle fracture
  • Ankle fracture (peds)
    • Tillaux fracture
• Foot and toe fractures

Foot and Toe Fracture Types

Hindfoot

• Talus fracture
• Calcaneus fracture

Midfoot

• Lisfranc injury
• Navicular fracture
• Cuboid fracture
• Cuneiform fracture

Forefoot

• Fifth metatarsal fracture
• Non-fifth metatarsal fracture
• Toe fracture

Evaluation

Weber A Oblique

Weber B Oblique

Weber B AP

Weber C Oblique

Weber C AP

• Ottawa Ankle Rules (sen 96-99% for excluding fracture)
• 3 views:
  • AP: Best for isolated lateral and medial malleolar fractures
  • Oblique (mortise)
    • Best for evaluating for unstable fracture or soft tissue injury
    • At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
  • Lateral: Best for posterior malleolar fractures
• Consider proximal tib/fib films and talus fractures

Classification (Danis-Weber System)

• System based on level of the fibular fracture and characterizes stability of fracture
• Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)

Type A

• Fibula fracture below ankle joint/distal to plafond
  • Medial malleolus often fractured
  • Tibiofibular syndesmosis intact
  • Usually stable: occasionally requires ORIF

Type B

• Fibula fracture at the level of the ankle joint/at the plafond
  • Can extend superiorly and laterally up fibula
  • Tibiofibular syndesmosis intact or only partially torn
  • No widening of the distal tibiofibular articulation
  • Medial malleolus may be fracture
  • Possible instability
    • Use gravity or weight bearing stress X-rays to determine stability

Type C

• Fibula fracture above the level of the ankle joint/proximal to plafond
  • Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
  • Medial malleolus fracture
  • Unstable: requires ORIF

Management & Disposition

General Fracture Management

• Acute pain management
• Open fractures require immediate IV antibiotics and urgent surgical washout
• Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
• Consider risk for compartment syndrome

General Ankle Fracture

• Determined by stability of fracture:
  • Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
  • Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint

Isolated lateral malleolar fracture

• If stable (see Weber classification) treat like severe Ankle Sprain
• Signs of instability:
  • Displacement >3mm
  • Associated medial malleolus fracture
  • Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
  • Widening of medial clear space (suggests deltoid ligament injury)

Isolated medial or posterior malleolar fracture

• Must rule-out other injuries
• If non-displaced, isolated:
  • Short-Leg Posterior Splint (ankle at 90^o)
  • Non-weight bearing
  • Refer to Ortho in 5-7d

Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture

Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.

• Short-Leg Posterior Splint (ankle at 90^o)
• Immediate reduction or ortho consult in ED

See Also

• Ankle (Main)
• Ankle Sprain
• Ankle Fracture (Peds)
• Ottawa Ankle Rules
• Maisonneuve Fracture
• Pilon Fracture
• Fracture (Main)
• Splinting

External Links

• http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
• Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378