An ankle fracture is one of most common broken bones people sustain. It typically occurs from a rotating or a twisting injury as a result of either a car accident or a sporting injury. Typically patients sustain a ligament sprain or strain first and then if the twisting is bad enough the ankle goes on to sustain a break.
It can be difficult after twisting an ankle to tell whether or not there’s actually a fracture or not. If there is a gross deformity apparent with the ankle where the bone comes through the skin, then it is not so subtle. If a person cannot bear weight on the ankle, or the pain remains intolerable despite over-the-counter pain medications, or numbness is present, then it will be a good idea to go to an emergency room or see your family doctor.
In the emergency room or at the doctors office, an exam will consist of checking to see if pulses are present and to make sure the patient can move the toes and that sensation is intact. In unusual circumstances, there may be issues with nerves or vessels being compressed from the broken bones. It may be necessary to expedite a reduction of the fracture (putting it back into place by manipulating it) quickly if this is what’s happening. X-rays can help tell whether not a fracture is present. If there is concern about whether or not the fracture goes into the ankle joint, a CAT scan may be necessary to see how bad the displacement is with joint involvement.
The most common place for an ankle fracture to occur is on the outside bone which is known as the fibula. This is called a lateral malleolus fracture and there are three different levels where the fracture may occur (above, below, or at the level of the joint). If the fracture is not out of place or barely displaced and the ankle is stable, surgery may be unnecessary. Some doctors will allow patients with this injury to bear weight right away, whereas others will have them on crutches with minimal or no weight for a few weeks.
If the fracture is displaced and the ankle shows instability on either physical examination or x-rays, surgery may be necessary. Patients are placed under general anesthesia for the procedure, and typically a temporary tourniquet is placed to minimize blood loss during the procedure.
Once the fracture area is reached during the operation, typically it is cleaned up and the bones are put back together to make it stable and a plate and screws are placed for stability purposes.
Treatment of a typical ankle fracture usually lasts between 30 minutes and an hour and a half. There are exceptions to this number however, so some of it depends on the experience of the surgeon and if there are any difficulties encountered during surgery.
If a fracture to the ankle occurs on the inside bones of the ankle, that is in the bone called the tibia. And that fracture is called a medial malleolus fracture. As with an ankle fracture on the outside bone, if it is non-displaced or it is a fracture below the level of the ankle joint and the pieces are small then surgery may not be necessary. If there is displacement and instability, surgery with a plate and screws or a wiring technique may help and be necessary.
In this area of the ankle, surgery may be considered even if there is no displacement of the fracture. There is a higher risk of the bones not healing in this area and if surgery is performed that healing potential increases and one can start moving the ankle earlier. Fractures on the inside of the ankle if they are impacted significantly may require bone grafting to lower the later risk of developing post traumatic arthritis.
Broken ankles that involve both the inside bone and the outside bone are called bimalleolar fractures. Along with the bony breaks, there are also ligament injuries and the ankle is inherently unstable when two bones are broken.
With a fracture of both sides (bimalleolar), these are considered unstable and operations are typically recommended. A splint may be placed if there is considerable swelling in order to let it go down prior to the procedure. Usually patients are not allowed to bear weight after surgery for approximately 6 weeks at which point the patients are allowed to start putting more more weight on the foot.
For the inside of the ankle, surgical techniques include either a plate and screws, screws by themselves, or potentially a wiring technique as well. There is a third area where fractures are sometime seen and this is the back part of the ankle called the posterior malleolus. This area is important to check on carefully because the piece of bone is covered by a lot of cartilage. If the broken piece on this area is larger than 25% of the ankle and is out of place by more than a couple millimeters, then surgery is typically indicated because otherwise there is a high chance it will not heal properly.
There are multiple options available for surgically treating a posterior malleolus fracture. One option is to place a screw from the front ankle to the back and another option is to go from the back of the ankle to the front, or a plate and a screw can be placed along the back of the bone which is called the tibia.
Along with a break of the ankle bone, the patient may have damage to the ligament that attaches the tibia bone to the fibula bone. This ligament is called the syndesmosis and injury to this by itself is known as a high ankle sprain. If it is associated with a broken ankle, then it may require an extra screw or two placed across the syndesmosis for extra stabilization.
Once the ankle fracture is operated on, healing in a normal situation takes around six weeks. If an individual is a smoker, or is older, or has diabetes or takes certain types of medications it may delay the healing considerably.
Complications that can occur after surgical treatment can include infection, bleeding, a blood clot in that leg, damage to tendons, nerves, or blood vessels, and a lot of pain. Additionally, the bones may have difficulty healing or post traumatic arthritis may set in. There also may be hardware related pain from the screws and rods used to fix the fracture. These can be removed months to years after the surgery once the bone has successfully healed. Once the bone is healed, the hardware is no longer really necessary. But most people don’t need it taken out.
Most surgeries for a broken ankle are fairly routine, however if the surgery involves significant trauma with high energy and the joint is involved, it can be a difficult surgery and there may be significant issues with swelling which may make it necessary to delay doing the surgery.