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An ankle fracture is a break in the far end of one of the 2 bones of the lower leg: the tibia (the inside or medial bone of the lower leg) and the fibula (the outside or lateral bone of the lower leg). Both bones end in a bony prominence (malleolus) that forms an arch on top of the talus, one of the bones of the foot. The ankle is a major weight-bearing hinge joint composed of three bones: the distal tibia, distal fibula, and talus. These 3 bones are joined together by 3 groups of ligaments that hold the ankle joint in place. The deltoid ligament is on the inside of the ankle, the lateral ligament complex is on the outside of the ankle; another group of ligaments holds the tibia and fibula together. The talus itself is usually not included in a diagnosis of ankle fracture.
Ankle fractures occur most commonly when there is a sudden twisting injury to the foot. The ankle may roll in (inversion injury) or out (eversion injury), and the force on the foot can be transmitted to the tibia and fibula, resulting in fracture. The physician will often try to ascertain exactly how the injury occurred. Knowing the position of the ankle at the time of injury can help determine the mechanism of injury, which gives important information about which bones and ligaments were probably damaged. Fractures also can occur in individuals with unstable ankle joints and a history of recurrent ankle sprains.
As with other types of fractures, ankle fractures are described as either displaced or nondisplaced. In a displaced fracture, the fractured bone segments have moved out of alignment, while in a nondisplaced ankle fracture they have not. Any type of ankle fracture can affect the joint surface and joint motion (articulation) and almost always involves concomitant ligament injuries.
The prominent malleolar surfaces on the medial and lateral sides of the ankle are the most commonly injured areas. When one of the three bony prominences is fractured, the break is referred to as an isolated malleolus fracture. A fracture involving two malleolar prominences is called a bimalleolar fracture, and fracture of both malleoli and the posterior portion of the tibia is a trimalleolar fracture.
Risk: Individuals who participate in activities that potentially place excessive force on the ankle joint (e.g., skiing, snowboarding, ice skating, basketball, football, soccer, rugby) are at risk for ankle fractures. Ankle fractures commonly occur in motor vehicle accidents where the foot is braced against the floorboard. Most males experiencing ankle fractures are under age 50, while most women experiencing ankle fractures are over age 50 (Iskyan). Incidence and Prevalence: In the US, the ankle is the joint most commonly injured. About 90% of sports-related injuries are ankle sprains, and 10 to 15% are ankle fractures (Steele). The incidence in the general US population is 187 per 100,000 person-years (Iskyan). As the population ages, the incidence of ankle fractures is increasing. |
Source: Medical Disability Advisor
| History: A thorough history should be obtained including any medical conditions (especially diabetes, osteoporosis, peripheral vascular disease), medication history (corticosteroids), history of foot and ankle injuries and surgeries, and events surrounding the current injury. The individual may be able to recall the foot either turning or rolling in or out in relation to the lower leg. The ankle may be swollen, painful, and discolored. Individual may report inability to bear weight immediately after the injury and an audible popping sound may have occurred at the time of injury. Physical exam: Observation of the lower extremity and ankle may reveal swelling, bruising (ecchymosis), deformity, and open wounds. Using the fingers to feel the ankle (palpation) can reveal focal bony tenderness and may localize the area of fracture. The presence and quality of pulses in the posterior tibial and dorsalis pedis arteries should be noted and compared with the unaffected ankle. Capillary refill time and neurological exam should be noted for both feet. Active and passive range of motion should be documented.
The physician will determine if the injury is stable or unstable; instability may include bony and ligamentous injury on both the inside and outside (medial and lateral sides) of the ankle. Unstable fractures usually require urgent orthopedic attention. The physician will also assess for joint dislocation and presence of other traumatic injuries. Tests: Since about 90% of ankle injuries are due to strains or sprains, ankle x-rays are reserved for suspected fractures. The Ottawa ankle rules developed by Stiell and colleagues are helpful in determining which individuals should receive X-rays. Three views of the ankle are standard. A standing view can help evaluate ligamentous instability. Radiographic comparison of the injured foot with the non-injured may be helpful in some cases. Occasionally, a CT or MRI may be ordered to evaluate joint surface changes, fracture position, ligaments, and soft tissue. After the bones have been realigned in their anatomically normal position (reduction) follow-up x-rays usually are necessary. |
Source: Medical Disability Advisor
| If the fracture is not displaced, treatment with cast or brace (immobilization) is usually sufficient for stable fractures. If the fracture is displaced, reduction is essential. This can be accomplished by either closed (nonsurgical) reduction or surgical reduction, internal fixation (ORIF). Stability of the fracture after reduction is critical to maintain ankle motion and prevent complications such as degenerative arthritis. Because joint stability depends on both bone position and ligament support, any injured ligaments must be treated along with the fracture to restore ankle stability. Post-reduction immobilization is necessary to maintain stability while healing occurs. Weight bearing is restricted for a period based on the type and location of the fracture, stability, and bone healing. Early mobilization of the joint while maintaining proper alignment of the bones should begin as soon as possible. |
Source: Medical Disability Advisor
| An ankle fracture that heals in perfect alignment usually leaves little or no impairment. Some individuals may be left with post-traumatic arthritis of the ankle joint, continued pain, or a tendency for recurrent ankle sprains. Fractures of the weight-bearing portion of the tibia have a more guarded prognosis, since any change in the anatomic position of the fracture fragments is likely to result in long-term post-traumatic arthritis. |
Source: Medical Disability Advisor
| Note on research and authorship The duration of treatment of an ankle fracture is related to the associated soft tissue involvement, location and type of fracture (Chapman). The main focus of rehabilitation should emphasize restoring full range of motion, strength, proprioception and endurance while maintaining independence in all activities of daily living (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit. Appropriate early mobilization of the ankle joint hastens recovery; however, protocols for initial rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).
The goal of rehabilitation is to decrease pain and restore full function, with a painless mobile ankle (Bucholz). Local cold application may be beneficial for controlling pain and edema (Mora). Individuals should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Gait training using appropriate assistive devices is indicated to promote independent ambulation (Bucholz). Individuals may progress from walker to crutches to cane based on ability and weight bearing status. If casted, range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. After cast removal range of motion, proprioceptive and strengthening exercises should be started at the ankle (Bucholz). Exercise intensity and difficulty should be progressed until full function is evident. Edema is a common problem and may be controlled using modalities such as cold packs and compressive wrapping. If operatively managed, the rehabilitation protocol will be directed by the treating physician.
Bone healing may occur within 6 to 12 weeks; however, the bone strength and the ability of the bone to sustain a heavy load may take up to 1 year. Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical ‡ | |
| Physical Therapist | | Up to 20 visits within 10 weeks | | | | | | | | Surgical | |
| Physical Therapist | | Up to 16 visits within 8 weeks | |
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| ‡ Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Complications can include tendon subluxation or disruption, wound infection, injury to the nerves and vessels in the area, non-union or delayed union of the fracture, ankle joint instability, degenerative arthritis, complex regional pain syndrome (CRPS), permanent loss of range of motion, and calcification of the ligaments. Delay in surgical treatment of a complex fracture or ligament injury can increase risk of complications. |
Source: Medical Disability Advisor
| Restrictions and accommodations include limited or no weight bearing for several weeks; use of crutches, canes, walker, or wheelchair; and limited standing, stair climbing, or walking. Rest periods may be necessary to allow for elevation of the foot and lower leg. Use of prescribed medications for pain control and inflammation may limit the individual's ability to drive a motor vehicle and operate heavy machinery. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Which bone(s) were fractured?
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Was fracture displaced or non-displaced? Was individual's ankle also dislocated?
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Was the weight-bearing surface of the tibia fractured?
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Has individual had routine ankle x-rays? Were standing views performed? Has individual had a CT scan or MRI?
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Does the post-reduction x-ray show good alignment of the fracture pieces, or is part of the fracture still out of position?
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Were any neurovascular structures compromised?
Regarding treatment:
- If the fracture was nondisplaced, was the joint immobilized?
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If the fracture was displaced, was closed or open reduction done? Was ORIF performed?
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Were there other injuries? Was ankle kept non-weight bearing?
Regarding prognosis:
- Did individual begin physical therapy at the appropriate time?
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Is individual actively involved and complying with physical therapy and home exercise program to strengthen the ankle?
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Does individual have any conditions that may affect ability to recover?
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Does individual have any complications that may prolong recovery?
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Source: Medical Disability Advisor
| Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 5th ed. Philadelphia: Lippincott, Williams & Wilkins, 2002.Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott, Williams & Wilkins, 2001. Iskyan, Kara, and Andrew Aronson. "Fracture, Ankle." eMedicine. Eds. Francis Counselman, et al. 15 Jul. 2008. Medscape. 12 Jan. 2009 <http://emedicine.medscape.com/article/824224-overview>. Mora, S., C. G. Zalavras, and David B. Thordarson. "The Role of Pulsatile Cold Compression in Edema Resolution Following Ankle Fractures: A Randomized Clinical Trial." Foot & Ankle International 23 11 (2002): 999-1002. National Center for Biotechnology Information. National Library of Medicine. 8 Oct. 2008 <PMID 12449403>. Steele, Phillip M., and John D. Kelly. "Ankle Fracture." eMedicine. Eds. David T. Bernhardt, et al. 5 Jun. 2006. Medscape. 12 Jan. 2009 <http://emedicine.com/sports/topic4.htm>. |
Source: Medical Disability Advisor
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