Ankle fracture

Ankle fractures are the most common fractures of the lower extremity. They are most often caused by twisting the ankle, the circumstances of which the patient will typically recall. The major symptoms are pain in the affected area and decreased range of motion. If physical examination and the patient history suggest a fracture (e.g., patient is unable to bear weight on the affected leg), an x-ray is performed. The most important diagnostic consideration is whether the fracture is stable (as is the case in isolated malleolar fractures) or unstable (e.g., bimalleolar fracture). Unstable fractures require surgery, whereas stable fractures can be treated conservatively with a short leg cast.

• Supination or pronation trauma (“twisted ankle”)
  • Supination/adduction → typically Weber A and B fractures (as well as a medial malleolus fractures)
  • Pronation/abduction → typically Weber C fracture

References:^[1]

Fracture	Stability
Isolated medial or lateral malleolar fracture	usually stable
Posterior malleolus fracture (refers to the posterior tibia)	usually unstable, as often associated with other malleolar fractures
Bimalleolar fracture (both medial and lateral malleolus)	mostly unstable
Trimalleolar fracture (medial, lateral and posterior malleolus)	always unstable

Weber classification of ankle fractures

The Weber classification categorizes ankle fractures according to the level of the fibular fracture in relation to the ankle syndesmosis (tibiofibular syndesmosis).^[2]

• Weber A: fracture below the syndesmosis (intact syndesmosis)
• Weber B: fracture at the level of the syndesmosis (possible syndesmotic injury)
• Weber C: fracture above the syndesmosis (ruptured syndesmosis, torn interosseous membrane)
  • Maisonneuve fracture:^[3]
    • Medial malleolus fracture or deltoid ligament tear
    • Syndesmosis rupture
    • Simultaneous interosseous membrane tears^[1]
    • High/subcapital Weber C fracture (or avulsion fracture of the lateral collateral ligament)

Special forms

• Avulsion of a bony fragment from the posterior tibial margin (Volkmann's triangle)^[4]
• Pilon fracture: fracture of the distal tibia that involves the tibial part of the talocrural joint and is frequently associated with fibular fractures^[5][6]

• Local pain, swelling and hematoma
• Tenderness, especially in the area of the malleoli, the syndesmosis, and the posterior aspect of the ankle joint
• Restricted range of movement
• Skin abnormalities (lacerations, discolorations, tenting, or blistering)
• If separation of the ankle mortise elements occurs → lateral displacement of the foot^[7]
• In some cases, accompanying injury (e.g., fracture of the proximal fibula, knee, or foot)

• Physical examination: Check for neurovascular deficits
• 3-view plain x-ray: Anteroposterior (AP); , lateral and oblique view
  • Evaluate articular surfaces
  • Compare joint spaces between talus and medial malleolus, talus and lateral malleolus, and talus and tibial plafond
  • Check for breaks in the ring of the ankle joint and for bony fractures

References:^[7]

• Initial management: rest, ice, compression, and elevation
• Conservative treatment
  • Indications: stable fractures (isolated/nondisplaced malleolar fractures)
  • Short leg cast for 4–6 weeks
• Surgical treatment: to ensure normal alignment of bone and cartilage to prevent ankle arthritis and to regain functionality
  • Indications: unstable/displaced fractures, open ankle fractures, and cases of neurovascular damage
  • Technique: reposition and internal or external fixation with metal plates and/or screws

References:^[7]

• General complications of fractures
• Damage to the peroneal or saphenous nerve
• Talar cartilage shearing injury (“flake fracture”)
• Avulsion fracture of Volkmann's triangle^[7]
• Post-traumatic osteoarthritis

References:^[8][9]

We list the most important complications. The selection is not exhaustive.