Ankle Fractures in Adults

Ankle fractures can affect anyone young to old. The paediatric and adolescent fractures are discussed in another link. This pertains more to the adult.

Mechanism of injury

This can be due to a high or low impact injury. Sometimes the patient may have simply missed a step and landed awkwardly.

The key is the position of the foot during the injury and the deforming forces which run through it at the time. A classification known as the Lauge-Hansen Classification was based upon this premise.

When should we suspect a fracture?

In general, fractures tend to be exquisitely painful and prevent the patient from standing and bearing-weight, much less walk. They’re usually associated with swelling as well.

What may confuse the issue is that an ankle contusion or sprain may also present the same way. However these don’t tend to be as painful, and the pain doesn’t last as long.

Should I get an X-ray?

There is no hard and fast rule regarding this. Some injuries may appear to be seemingly innocuous but may actually belie an occult fracture.

By the same argument, some of these occult fractures may be so inconspicuous that they may not show up on X-ray and may require further imaging such as an MRI or a CT to diagnose it.

A set of guidelines, the Ottawa Rules, recommends an X-ray if there’s pain in the ankle area with an inability to bear weight both immediately and in the emergency department.

We recommend the patient consult a doctor so an in-depth examination can be performed before deciding if any or further imaging is warranted. Occasionally, a patient may have a condition blunting their response to pain, and this might obfuscate the situation.

Ankle fracture pre opFigure 1. X-rays of an ankle injury.

Is surgery Mandatory if the diagnosis is indeed that of a fracture?

There are many considerations in treating the “simple” ankle fracture. Not every fracture demands surgical fixation.

Factors such as the amount of displacement, soft tissue injury, concomitant injuries (such as ligamentous complex injuries), patient’s pre-morbid status (underlying chronic diseases such as diabetes mellitus, cardiac conditions etc), patient’s level of activity are judiciously considered before one decides if surgery is necessary. These would also determine the type of surgery to be performed.

In some cases, the overlying soft tissue is so badly traumatised that the traditional approach to ankle fixation may lead to a risk of the skin breaking down which would then have a deleterious effect on the healing and can lead to infection.

These might require the use of smaller incisions with smaller implants which may not have as robust a stabilisation effect. We would then combine the fixation with the use of a circular ring fixator to offload the fractured fixation. The advantage of this construct is also such that one may return to weight-bearing earlier.

Figure 2. Ankle Fracture Treatment X-raysFigure 2. X-Rays showing ankle stabilised temporarily in a Backslab.

Figure 3. ankle fracturesFigure 3. X-Rays showing the more traditional Open Reduction Internal Fixation of the Fracture

In some cases, the overlying soft tissue is so badly traumatised that the traditional approach to ankle fixation may lead to a risk of the skin breaking down which would then have a deleterious effect on the healing and can lead to infection.

These might require the use of smaller incisions with smaller implants which may not have as robust a stabilisation effect.

We would then combine the fixation with the use of a circular ring fixator to offload the fractured fixation. The advantage of this construct is also such that one may return to weight-bearing earlier.

Figure 4. ankle fracturesFigure 4. X-Rays of the ankle injury.

Figure 5. ankle fracturesFigure 5.  X-Rays showing the Internal Fixation of Ankle was performed with Circular Ring Fixator as an adjunct.

Figure 6. ankle fracturesFigure 6. X-Rays showing the Ankle Fracture healing with the Circular Ring Fixator removed.

What if the diagnosis was missed initially? Is there any recourse?

It is always ideal to treat the fracture fresh in order to obviate the chance of further damage and early arthritis. However, sometimes the patient may present late with such a scenario.

We would perform a detailed examination and request for imaging to plan the various options available.

These may range from breaking the badly-healed fracture (osteotomy) and re-fixing the fracture with bone graft, to the use of circular ring fixators to perhaps fusing of the joint.

Figure 7. ankle fracturesFigure 7. X-rays of a delayed presentation fracture which was treated elsewhere.

Figure 8. ankle fracturesFigure 8. X-rays – Malunion and non-united sites taken down and fixed with bone graft and Hybrid Fixation.

Figure 9. ankle fracturesFigure 9. X-Rays of the ankle with the Circular Ring Fixator removed.

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