Causes

            Ankle fractures result when the ankle is forced past the normal range of motion.  Any one of the bones of the ankle joint can break as the result of a fall, car accident or other trauma to the ankle.  It may also result form a twisting injury or crush injury.  Although fractures tend to cause pain, you may be able to walk on it.  How ever this is not a good idea, and a physician should check your injured ankle.

Types

            Ankle fractures are classified in various ways.  An important distinction is weather it is a fracture of the malleolus or a much more severe tibial planafold (pilon) fracture.  Fractures can be displaced or non-displaced.  A displaced fracture is a break weather the bone fragments is poorly aligned.  Anon-displaced fracture is one in which the break is “clean” and the fragments are in good alignment.

Tibial Planafold Fracture “pilon fracture”

            A tibial planafond fracture is usually the result form a high-energy trauma, like a fall from a height or motor vehicle accident.  Patients experience immediate pain and cannot walk.  There is significant swelling with or without deformity.  These fractures involve the weight-bearing surface of the joint and usually require surgical treatment.  Besides the fractures, there is a lot of injury to the surrounding soft tissues.  Surgery is required to stabilize the fracture.

Malleolus Fracture

            Fractures of the malleolus are the most common type of ankle fractures.  They can involve the medial, lateral or both sides of the ankle.  They are usually the result of a twisting injury.  Ligament damage is typical with this time of fracture.  Patients feel immediate pain and gave difficulty walking or cannot walk at all.  Moderate to severe swelling and tenderness are present around the fracture site. There will be bruising and there may or may not be a visible deformity.

            Initial treatment is a closed reduction and casting followed by ice and elevation... a closed reduction is when the doctor manually readjusts the position of the bone.  If the fracture is reduced (put into good alignment) well, it can be managed in a cast. If a closed reduction does not bring the bones into good alignment, doctors recommend a surgery called an open reduction with internal fixation.  They use plates and screws to put the bones into anatomic alignment.

            Most people with these fractures require 6 weeks of immobilization in a cast.  When treated with a closed reduction, patients are typically required to wear a long leg cast for 2-4 weeks followed by a short leg non-walking cast for 2-4 weeks.  People who have had surgery to repair their fracture will wear a short leg non-walking cast for 6 weeks.  After the bone is healed, physical therapy is started to for range of motion exercises and strengthening.  Most patients with malleolus fracture will require 3 months for a full recovery.

Maisonneuve Fracture

            A maisonnueve fracture in an uncommon fracture caused by rotating the ankle outward causing pain on the inside of the ankle  it involves a fracture near the end of the fibula that is a serious injury despite minor findings on x-ray.  Symptoms include tenderness on the near the fracture site and on the proximal fibula near the knee.  If there is tenderness on the proximal fibula, x-rays should be taken of the bones of the lower leg.  X-rays of the ankle may show a small avulsion fracture of the medial malleolus with a small increase in the space between the two bones of the lower leg.  X-rays of the lower leg above the ankle will show a fracture of the fibula.

            These fractures require surgery that involves the placement of one or two screws to hole the fibula and tibia while they heal if the fracture of the fibula is in poor alignment, it may require surgery.  The healing time is approximately 6 weeks in a non-weight bearing short leg cast.  Then you will get a walking cast and begin physical therapy for 6 weeks.  Sometimes the screws are taken out 8-12 weeks after surgery.

Calcaneous Fractures

            Calcaneous fractures are the result of high-energy injuries that are quite serious.  Patients have severe heel pain and cannot walk.  There is moderate to severe swelling and tenderness over the fracture.  Initial treatment includes immobilization in a bulky splint with ice and elevation to control swelling.  If the fracture is in poor alignment, or involves the joint surface, surgery will be required.  Casting is usually 6 weeks long in a non-weight bearing short leg cast.  Patients usually experience residual stiffness after these fractures.  For fractures that are in good alignment and aren’t treated surgically, treatment includes 6 weeks of casting in a non-weight bearing short leg cast.

Avulsion Factures

            An avulsion fracture (where ligaments or tendons pull away from the bone causing a small fracture) can occur with calf muscles contract and pull away from the bone.  If the fracture is in good alignment, it can be treated in a non-walking short leg cast for 6 weeks.  If the fracture is in poor alignment, it may require surgery.

Talus Fracture

            Talus fractures occur most often in parts called the dome or neck, but can also occur in the lateral process.  The talar neck is uncommon but deserves mentioning because the neck of the talus is where the entire bone receives its blood supply.  A fracture in this area can disrupt the blood supply causing the bone to die.  This process is called avascular necrosis.  It is caused by a high impact trauma where the foot is pushed upward, for example when the foot is over flexed in a car accident when the foot is on the break.  Symptoms include severe hind foot pain, moderate to severe swelling and bruising and tenderness over the ankle.

            If the talar neck fracture is in poor alignment, it is a true surgical emergency.  The fracture must be repaired immediately so the bone does not lose its blood supply.  If the bone dies, it can collapse and become arthritic, leading to an ankle fusion.  Even if the bone heals well and there is no evidence of avascular necrosis, there will be residual stiffness and pain.   After surgery you will have a non-weight bearing short leg cast for at least 6 weeks.  If the fracture is in good alignment, it can be treated in a non-weight-bearing short leg cast for at least 6 weeks.  Casting will be followed by physical therapy.

            The lateral process of the talus can fracture, though it is very uncommon.  It results in chronic ankle pain.  Symptoms include pain on the outside of the ankle with selling and tenderness.  If the fracture is in good alignment, it can be treated in a non-walking short leg cast for 6 weeks.  If the fracture is in poor alignment, surgery is indicated followed by 6 weeks of casting.

            The dome of the talus can develop a chronic condition known as osteochondritis dissecans (OCD).  It is the result of repetitive trauma, like pounding on a hard surface).  An OCD lesion can appear as a cyst or loose piece of bone.  Pain usually has a gradual onset that is activity related.  If the fragment is loose, you will notice a clicking or locking of the ankle.  If the fragment is in good alignment, it can be treated with casting.  In more chronic cases, or when the fragment is in poor alignment, an ankle arthroscopy will be performed to remove the fragment(s).  Weight bearing is avoided for 6 weeks followed by physical therapy.

Casting

            To make sure the bone is aligned properly, x-rays are taken.  Then you will be placed in a splint or cast.  This is to hold the bone in place while it heals.  You may have to wear a cast any where from 4-10 weeks.  When your fracture is treated you will be instructed to decrease your activity, take medication for pain, and elevate and ice the extremity.  You will be asked to keep your cast dry.  To decrease swelling and control pain, elevate your leg above the level of you heart.  This simple action combined with icing for 20 minute intervals can help control your pain without medication.

            Protect your ankle by giving it time to heal.  When you do become active again expect some swelling and stiffness.  Usually after casting, physical therapy is started to rebuild strength and avoid re-injury.  Exercise can increase the flexibility of your ankle support your feet by wearing flat, stable shoes.  High-top lace up shoes with good heel and arch support may be your best choice.  For extra support you may need an ankle brace.