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Ankle Fracture – Causes, Symptoms and Treatment

An ankle fracture is a break in one or more of the bones forming the ankle joint. It commonly results from twisting or a fall and often requires targeted medical treatment.

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Things worth knowing about "Ankle Fracture"

An ankle fracture is a break in one or more of the bones forming the ankle joint. It commonly results from twisting or a fall and often requires targeted medical treatment.

What Is an Ankle Fracture?

An ankle fracture refers to a break in one or more of the bones that make up the ankle joint (articulatio talocruralis). The most commonly affected bones are the medial malleolus (inner ankle), the lateral malleolus (outer ankle, part of the fibula), and the posterior malleolus (back portion of the tibia). The ankle joint connects the lower leg to the foot and is essential for walking, standing, and running.

Causes

Ankle fractures are most often caused by sudden, forceful stress on the joint. Common causes include:

Twisting of the foot (supination trauma) during sports or everyday activities
Falls from height with impact on the foot
Motor vehicle accidents
Direct blows or crush injuries to the ankle area
Stress fractures from repetitive overuse (e.g., in competitive athletes)

Symptoms

The symptoms of an ankle fracture are typically immediate and pronounced after the injury:

Severe pain around the ankle, especially with weight-bearing
Swelling and bruising around the ankle joint
Visible deformity of the joint in more severe fractures
Limited or absent range of motion in the foot
Tenderness when pressing on the malleoli
A feeling of instability in the joint

Classification

Ankle fractures are commonly classified using the Weber classification, which is based on the level of the fibular fracture in relation to the syndesmosis (the ligamentous connection between the tibia and fibula):

Weber A: Fracture below the syndesmosis, usually stable
Weber B: Fracture at the level of the syndesmosis, variable stability
Weber C: Fracture above the syndesmosis, often unstable with syndesmotic injury

In addition, bimalleolar fractures (involving both malleoli) and trimalleolar fractures (involving all three malleoli) represent more complex injury patterns requiring more extensive treatment.

Diagnosis

Diagnosis is established through a combination of clinical examination and imaging studies:

Physical examination: Palpation of the ankle, assessment of mobility and stability
X-ray: Standard imaging method for detecting fractures around the ankle (performed in two planes)
Computed tomography (CT): Used for complex fractures or detailed surgical planning
Magnetic resonance imaging (MRI): To assess ligament or cartilage injuries

The Ottawa Ankle Rules are a validated clinical decision tool that helps physicians determine whether imaging is necessary after an ankle injury.

Treatment

Conservative Treatment

Stable fractures (e.g., Weber A) can often be managed without surgery. Treatment measures include:

Immobilization with a cast or orthotic boot
Non-weight-bearing with crutches
Icing and elevation of the leg to reduce swelling
Pain management with analgesics (e.g., ibuprofen, paracetamol)
Thromboprophylaxis (anticoagulation) during periods of immobilization

Surgical Treatment

Unstable or displaced fractures (e.g., Weber B with instability, Weber C) typically require surgery:

Open reduction and internal fixation (ORIF): Bone fragments are repositioned and secured with plates, screws, or wires
Syndesmotic screw fixation: Used when the syndesmosis is disrupted to restore stability between the tibia and fibula

Rehabilitation

After initial treatment, targeted physiotherapy is essential for a full recovery. This includes strengthening exercises, balance training, and a gradual return to full weight-bearing. Complete rehabilitation may take between 6 weeks and several months, depending on the severity of the injury.

Possible Complications

Post-traumatic osteoarthritis of the ankle joint
Chronic joint instability
Wound healing problems following surgery
Deep vein thrombosis or pulmonary embolism during prolonged immobilization
Malunion (improper healing) of the bone

References

Rüedi, T. P., Buckley, R. E., Moran, C. G. (Eds.) - AO Principles of Fracture Management, 2nd edition, Thieme (2007)
Stiell, I. G. et al. - The Ottawa Ankle Rules. Annals of Emergency Medicine, 26(4), 484-491 (1995)
Hak, D. J., Egol, K. A. - Ankle Fractures. In: Rockwood and Green's Fractures in Adults, 9th edition, Wolters Kluwer (2020)

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