Unstable ankle fracture before and after repair

 

Ankle Fractures

 

Ankle fractures are common injuries that result from low energy twisting injuries or falls.  The ankle is divided into two main areas: Medially around the inside part of the ankle and laterally around the outside part of the ankle.  There are two bony projections from each side of the ankle which can be injured and treatment depends on the stability of joint and whether the cartilage surface is intact. The bony projections are called malleoli (singular malleolus) so we describe the fractures in terms of which malleoli are broken. 

 

 

Lateral Malleolus fracture with subluxation of the talus

 

 

 The most common type of fracture is called a lateral malleolar fracture; this involves the outer portion of the ankle.  Most of these are low energy injuries which can be treated successfully with cast immobilization followed by protected weight bearing in a removal cast boot. If the talus (the square shaped bone at the top of the foot) is shifted then I will generally recomend repair using plates and screws.  Most lateral malleolar fractures can be treated without surgery but need to be immobilized in a cast or cast boot for 6 weeks to ensure the bone heals properly.

 

 

Medial malleolus Fracture

 

Medial malleolus fractures are a result of an eversion injury and are less common than lateral malleolus fractures.  Typically the foot is slighltly exernally rotated and these fractures typically occur during sporting activities such as soccer and football or stepping of an uneven surface such as a curb. Many patients are wearing cleates at the time of the injury which prevents the ankle from sliding against the turf or grass. The diagram below show a medial sprain of the ankle, but the mechanism for a medial malleolar fracture is identical. Unlike lateral malleolar fractures, most medial malleolar fractures require surgical repair.  The reason for this is that many times soft tissue becomes trapped within the fracture and prevents healing of the bone fragments together.  I repair medial malleolar fractures unless they are completely non-displaced.  After surgery I keep patients non-weight bearing for about 4-6 weeks depending on the severity of the soft tissue injury and swelling.

 

 

 

 

    

 

Inversion injury with medial ankle swelling and bruising

 

 

 If both bony projections are fractured, these are referred to as “bimalleolar” ankle fractures.  In most cases, these fractures are unstable and should be treated surgically unless there are other factors which would prevent surgical treatment.  Surgery usually involves a 1 hour outpatient procedure to re-align the bones of the ankle and hold them with plates and screws.

 

 

Bimalleolar fracture before and after repair

 

 

Trimalleolar fractures are high energy injuries in which both the lateral and medial malleolus are fractured as well as part of the end of the tibia called the posterior malleolus.  These are often associated with a dislocation of the ankle at the time of the injury.  These fractures are very unstable and because the soft tissue injury is pretty severe, I will often wait 5-10 days before proceeding with surgery to let the area around the ankle "cool off".  Doing the surgery too soon can result in wound problems and infection.  Unlike other ankle fractures, the surgery is more involved and I usually keep patients in the hospital overnight for pain control.

 

    

 

3D CT scans of a tri-malleolar ankle fracture

 

 

The last type of ankle fracture is called a syndesmosis disruption.  Although it is technically a disruption of the ligament between the two bones of the ankle joint, it behaves clinically like an ankle fracture.  The mechanism is similar to a medial malleolar fracture in that the foot is everted at the time of the injury but instead of a fracture of the medial malleolus, the deltoid ligament (a strong triangular ligament on the medial side of the ankle) tears and the fibular shaft fractures several inches above the ankle joint.  This fracture requires surgery to repair the ligaments between the tibia and fibula, and failure to recognize and repair these types of fractures leads to long term instability and pain in the ankle. 

 

    

 

Syndesmosis disruption before and after repair

 

 After surgery I place patients in a soft cast and have them non weight bearing for a total of about 4-6 weeks. Although patients don't like having to wear casts (especially in the summer months) they provide a lot of protection to the ankle during the healing process. Most patients will have a splint on their ankle after surgery.  The skin is wrapped in a soft cotton layer with a strip of plaster that runs down one side, under the heel and up the other side.  The splint allows some swelling of the ankle without damaging the skin or tissue around your surgery site. I have patients return to the office after about 10-14 days and we covert the splint to a regular short leg cast.  I change the cast every 3 weeks to check the skin and ensure it fits properly so most patients have one splint and two casts before they are done.  Sometimes I will put patients into a cam walker or cast boot after they come out of the cast if they have a particularly difficult fracture.

    

 

Cam boot (R) and a short leg cast (L)

 

 

  I recommend most people buy a cast cover during these 6 weeks.  Cast covers are inexpensive, pre-formed plastic bags that fit over your cast and have a plastic diaphram at the top.  They are much easier to use than trash bags and rubber bands.  I have included a couple of links where you can look at them online and decide if they are right for you.  I highly recommend them!

 

Example of a model putting on a cast protector

 

http://castcoversnow.com/

 

 

http://www.nextag.com/waterproof-cast-covers/search-html 

 

 

http://www.brokenbeauties.com/fashion-new/castcovers-arm.php 

 

After the cast comes off many patients complain of stiffness and swelling in the ankle and foot.  This is normal and represents your body's repsonse to the stress of walking again. During this time exercises and physical therapy are started to allow some improvement in motion. Total healing time takes 6-8 months and the ankle stays swollen to some extent for up to one year.  The screws and plates can irritate the ankle and in those cases I recommend removal of the plates and screws after 12 months. This is a short outpatient surgery that usually takes about an hour to perform and the use of crutches or protected weight bearing after surgery is not indicated.

 

Most patients have persistent swelling in the ankle that often lasts for 6-8 months after surgery.  This is normal and is not due to some additional injury.  For most people, I recommend using a compressive stocking suh as T.E.D. hose to help control the swelling.  You should put the stocking on first thing in the morning and take it off at the end of the day.  This can make a noticable difference in swelling and I encourage my patients to start using TED hose as soon as they are out of the cast and have their stitches out.  I've included a lin to the TED hose website below

 

 

http://tedhose.com/

 

For more information about the surgery and what to expect during and after your surgery (if you are going to have your ankle fixed) I suggest looking at the link below for ankle surgery instructions.  It has additional information about when, where and how that you may forget to ask in clinic

 

Ankle Surgery Instuctions