February 8, 2018
You fall and injure your ankle. Next you gauge your pain and ask: “Is it a broken ankle or a sprain?” This scenario accounts for one of the most common complaints; yet a simple twist and fall could become a complex injury involving bone, cartilage, ligaments and tendons. In this blog I will discuss ankle fractures and what the next steps are on the road to recovery.
Three bones make up the ankle: the tibia, the fibula, and the talus. The tibia and fibula are commonly involved in a broken ankle (ankle fracture). These articulate in multiple directions to account for the ankle’s complex range of motion. Motion between bones occurs against smooth surfaces covered with cartilage. Cartilage allows for fluid motion at a joint due to its low level of friction. For those familiar with carpentry, you can think of these bones as a mortise and tenon joint where the talus bone acts as the tenon (tongue) attached to the foot and the tibia and fibular act as the mortise making up the lower leg.
These bones are secured by ligaments (deltoid, syndesmosis, lateral ligament complex) that maintain this relationship. The deltoid ligament originates from the medial malleolus (medial tibia) and inserts on the talus, calcaneus and navicular bones of the foot distally. While commonly injured, surgical repair of this ligament is often unnecessary. The lateral ligament complex includes the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The most common type of ankle sprain involves the ATFL. The third major ligament complex is called the syndesmosis. This connects between the fibula and tibia throughout the lower leg. Injuries to this ligament are often referred to as a “high ankle sprain” and develop with rotation.
Pain free motion of the ankle relies heavily on this complex congruent relationship between the talus and the tibia and fibula. If the ankle joint is even displaced 1mm, a 42% increase in pressure to ankle may occur1. A change in the bony anatomy of the ankle involved with an ankle fracture may introduce enough change in alignment that the ankle is now at risk for future arthritis.
Is the Ankle Sprained or Broken?
A thorough evaluation by an Orthopedic Specialist in Foot and Ankle such as Dr. Miller will identify the nature of the injury. Immediately following the injury, it is reasonable to assess the ankle with weight bearing. If there is no pain with walking, an ankle fracture is highly unlikely. Soreness with walking but the ability to walk normally suggests a contusion or sprain of the ankle. However, if you cannot stand on the ankle, an evaluation is warranted to rule out a broken ankle or ankle fracture.
Swelling is another sign of injury. If the swelling comes on gradually and is mild, the injury is likely a sprain or less severe. More immediate and significant swelling indicates a bony injury and possible fracture. When severe fractures occur, blistering of the skin is not uncommon. The blisters emanate from excessive swelling in the soft tissues following a severe fracture. Sometimes the ankle is dislocated with this amount of swelling. Immediate medical attention is required in these circumstances to reduce the ankle. Once severe swelling or blistering sets in, this can take weeks until the initial swelling resolves. In many cases these changes can delay surgery on the ankle.
As time passes ecchymosis (bruising) may occur. This can be extensive; however, this does not necessarily mean the ankle is broken. More severe ankle sprains present with significant ecchymosis over the region of injury. Besides not being able to put pressure down on the ankle or a deformity in the ankle after injury, a good reason to be evaluated for a broken ankle/ankle fracture is continued symptoms that worsen or stay the same. Some ankle fractures are stable enough that you may still be able to walk. Some people have a high pain tolerance that allows them to cope with the injury. These scenarios are best evaluated by an orthopedic surgeon when not improving.
Once you have made the decision to be evaluated for ankle pain, Dr. Miller will assess you and your injury as a whole. This includes a detailed history and physical examination with special focus on the ankle. Your age, mobility level and medical history are important, particularly as it relates to the ability heal an injury or recover from a potential surgery. Preexisting medical conditions such as diabetes, vascular problems, and inflammatory disease (e.g. rheumatoid) must be accounted for during the planning of treatment. Any remote history related to the ankle or previous injury should be known.
Physical examination will be performed during your visit. It is important to assess the ankle based on its appearance including deformity, any open wounds around the ankle, the amount of swelling present, and any preexisting rashes or skin issues. Vascular exam is used to determine the appropriate blood flow to the lower extremity, and this is performed by checking the dorsalis pedis and posterior tibialis pulses surrounding the foot and ankle. A neurological exam of the lower extremity will be used to assess any nerve injuries and the ability to move the foot. The extremity will then be evaluated for areas of tenderness and pain. This will help to locate the injury in a broken ankle more specifically and rule out other concurrent pathology.
Findings from the physical exam will then be used to evaluate radiographs of the affected ankle and surrounding areas. X-rays consist of three views of the ankle and any other areas of concern. While minimizing radiation is a good general rule, lower extremity x-rays use very low levels of radiation and in comparison account for a small fraction of the radiation you naturally receive yearly by living on Earth2. Based on these images, Dr. Miller can evaluate for the presence of a fracture and the severity of the fracture.
Once you have been identified to have a broken ankle/ankle fracture, how will the ankle be treated? Assuming you have an ankle fracture, the most important decision is whether the fracture can be treated non-surgically or the broken ankle requires surgical intervention. This decision would be made by Dr. Miller taking into account all variables described above.
In many cases the decision to perform surgery depends on the stability of the ankle. If 2 or more different fractures are identified in the ankle, surgery is commonly warranted due to the concern for instability and movement of the pieces. If the pieces heal non-anatomically, the ankle may be predisposed to accelerated wear and arthritis. If only one fracture is identified, the decision to perform surgery relies on the location and character of the fracture. Further radiographs that stress the ankle may be warranted to make this determination.
If the broken ankle has been considered stable enough to not require surgery, early weight bearing in a protective boot may be an option. This type of protection can be required for 6 weeks. You would wear the boot during all weight bearing activities. Usually at 6 weeks there is adequate healing to start weaning out of the boot.
If the broken ankle/ankle fracture is severe or unstable, surgical intervention utilizing metal implants is likely required. The day of surgery a patient typically will receive a nerve block prior to surgery that helps with anesthesia and pain control after the procedure. This process anesthetizes the leg to achieve temporary numbness. Once this is complete the actual surgery usually lasts between 1 and 2 hours. The surgery consists of reducing the broken pieces of the ankle to where they were prior to the injury and maintaining that reduction with metal hardware. Generally one or two incisions are used. A soft cast or splint would be applied for temporary protection until you return the office. After surgery it is imperative to elevate your leg to your heart level consistently until seen in the office. This improves pain relief and wound healing.
When you return to the office, the ankle is usually ready to be placed in a boot for protection. For the next 5-6 weeks no weight is to be put on the leg in most cases. One can start showering 2 weeks after the surgery on average. Around 6 weeks after the surgery, you can progressively apply weight to the leg while in the boot until you are completely weight bearing in the boot without an assist device. Range of motion and therapy begins 4-6 weeks after surgery. You can drive 9 weeks after surgery if your right leg was injured. Eleven to 12 weeks after surgery the boot is replaced with a shoe and possibly an ankle brace. Return to full impact and running would be achieved in the following months.
1 Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976 Apr;58(3):356-7. Epub 1976/04/01.
2 Coughlin MJ, Saltzman CL, Mann RA. Mann’s Surgery of the Foot and Ankle: Expert Consult-Online and Print: Elsevier Health Sciences; 2014.