Ankle Fracture

Last updated 12/09/14

Definition

• Ankle injury resulting in a fracture of the bones of the ankle joint

Features

• Typically fracture of fibula
• +/- fracture of tibia & syndesmosis
• Classification assists in determining extent of associated ligamentous injury and therefore the stability of the joint
• Two joints involved with ankle fractures
• Ankle joint: tibia, fibula, talus articulation
• Syndesmosis: tibia and fibula

Causes

• Pronation with adbuction
• Pronation with eversion
• Supination with abduction
• Supination with eversion

Associated S/S

• Ankle pain
• Ankle swelling
• Bruising
• Soft tissue disruption or displacement: open fracture
• Deformity: ankle dislocation

Types of Fracture

• Weber A
• Infrasyndesmotic
• 20-25% of ankle fractures
• Syndesmosis remains intact
• Caused from adduction force on supinated/inverted foot
• Stage 1: Lateral collateral ligaments rupture or cause avulsion of lateral mallelus below syndesmosis
• Stage 2: oblique fracture of medial malleolus (very uncommon)
• Weber B
• Transsyndesmotic
• Usually partial, less commonly total rupture of syndesmosis
• Stage 1: rupture of anterior syndesmosis
• Stage 2: oblique rupture of fibula
• Stage 3: rupture of posterior syndesmosis or fracture of malleolus tertius
• Stage 4: avulsion of medial malleolus or rupture of medial collateral bands
• Weber C
• Suprasyndesmotic
• Usually total rupture of syndesmosis with ankle instability
• Stage 1: avulsion of medial malleols or ligamentous rupture
• Stage 2: rupture of anterior syndesmosis
• Stage 3: fibula fracture above syndesmosis
• Stage 4: avulsion of malleolus tertius or rupture of posterior syndesmosis

Weber Classification of Ankle Fracture

Complications

• Open fracture
• Ankle dislocation
• Instability

Investigations

• Ankle examination
• Neurovascular status
• Ankle X-ray
• Lateral
• AP
• Mortise views
• Angulated AP view to best see joint of tibia, talus & fibula

Management

• Acute Management
• Analgesia
• Management of open fracture as required
• Avoid prehospital reduction of fracture/dislocation unless neurovscularly compromised or prolonged transport
• Splint
• Jones dressing
• Short leg stirrup
• If dislocated or neurovascularly compromised perform closed reduction
• Procedural sedation
• Or Haematoma block
• Orthopaedic Referral
• Weber A
• Responds well to closed reduction
• If undisplaced or minimally displaced & no medial injury: walking cast for 6-8 weeks
• Strongly consider DVT prophylaxis
• Surgery if displaced, unstable, lateral malleolar fracture with soft tissue disruption
• Weber B
• Consider non-operative management if stable
• Splint & repeat x-ray in 3 days to assess for lateral stability
• If evidence of lateral instability or involvement of medial malleolus then for surgery
• If stable then continue conservative management
• Non weight bear for 4-6 weeks then reassess
• Surgery if unstable or suspected injury of deltoid ligament
• Weber C
• Due to rupture of syndesmosis are unstable and require ORIF

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References

1. eMedicine: Ankle Fracture 17/10/2012
2. Wheeless Textbook of Orthopaedics: Ankle Fractures
3. Radiology Assistant: Ankle Fracture
4. Pic: Weber Fractures