Ankle Fractures

An ankle fracture is a break in one or more of the bones of the ankle joint – the tibia, fibula and talus. Two joints are involved in ankle fractures:

• Ankle joint – where the tibia, fibula and talus meet.

• Syndesmosis joint – the joint between the tibia and fibula.

The ankle is a complex joint that is capable of a wide range of movement: flexion, extension, inversion and eversion as well as a combination of these movements. This allows movement and balance on both level and uneven ground. The ankle takes the full weight of the body and is subject to considerable force, particularly in running and jumping.

Many ankle injuries are managed conservatively. However, obvious clinical deformity (i.e dislocation) or injuries with neurovascular compromise of the foot are an orthopaedic emergency, for which immediate reduction is required.

Severe sprains and fractures can present in a similar manner. Typical symptoms are of:

• Immediate, severe pain, which may extend from foot to knee.

• Swelling, localised or along the leg.

• Bruising.

• Tenderness.

• Inability to weight bear, although patients do sometimes walk on ankle fractures.

• Joint deformity.

If you think you have broken the ankle joint seek medical help as soon as possible. NHS advise you call 111 or go to an urgent care centre.

Classification

Danis-Weber Classification

• Type A: fibular fracture below the syndesmosis, which is intact.

• Type B: fibular fracture at the level of the syndesmosis.

• Type C: fibular fracture above the syndesmosis, indicating rupture of the syndesmosis.

• Rolling the ankle, either in or out.

• A sudden twisting motion.

• A rapid bending or extending motion of the joint.

• Heavy landing such as a fall from a height.

• Direct trauma such as a crushing injury or a road traffic accident.

Based on the mechanism of injury, symptom severity and clinical presentation when seen in clinic, your Physiotherapist will have the knowledge and experience to provide you with an accurate and timely diagnosis which will ensure the most effective treatment and management plan is put in place.

If an ankle fracture is suspected, your Physio will strongly urge you to attend hospital where the team assessing a suspected fracture may take an X-ray – to determine whether a fracture is displaced or not displaced. A displaced fracture is less common and may need to be properly lined up and stabilised. This may involve an anaesthetic and potentially metal pinning or plating of the bones.

CT or MRI scans are sometimes needed for:

• Identification of subtle fractures (e.g. talar fractures) which can be difficult to see on plain X-ray.

• Assessment of ligamentous injuries.

The Physiotherapist can also answer any questions you may have about your pain, such as what is causing the pain and the likely recovery time with your rehabilitation programme. A plaster cast or a special boot is used to manage a fracture where the bones are stable and have not moved position. You will be provided with walking aids such as elbow crutches and may be instructed to keep your weight off the injured foot. Your Doctor/Physiotherapist will discuss with you how long you should expect to wear the plaster or boot and explain how much weight you can put on that leg when standing or walking.

You may need to take medication in order to manage your pain. Your Physio/Doctor will discuss this with you. You can also wriggle your toes regularly. After your cast is removed the ankle has not been moving for several weeks, it is common to experience:

• Pain.

• Reduced movement/stiffness.

• Decreased strength.

• Muscle wasting (from lack of movement).

• Swelling.

The choice between conservative and operative treatment will depend on individual circumstances. Evidence as to which produces the best long-term outcomes is mixed and sometimes contradictory, although a 2012 review concluded that generally unstable fractures fare better with surgical treatment, the decision being based on the degree of distal fibular dislocation and the fracture type.

A 2015 randomised controlled trial compared a supervised exercise programme with individually tailored advice about self-management (prescribed, monitored and progressed), both delivered by a physiotherapist; it found that they were equally effective.

A combination of early mobilisation, early commencement of weight-bearing and the use of a removable immobilisation device, in conjunction with exercise, has a positive effect on ankle range of motion. Your clinician at Pure Physiotherapy will help guide you through the most appropriate treatment and management. They will devise a personalised and progressive rehabilitation programme for you and will regularly re-assess for progress so that your exercises can be changed.

Your Physio may also use hands on treatment techniques such as joint mobilisation and deep tissue massage to reduce pain and swelling, improve range of motion and help to restore function.

Your bone may be out of alignment or be unstable and therefore you will need to have an operation to ‘fix’ the bone in place with a plate or screws. After surgery, your leg will be in plaster and you may be discharged quickly.