Broken Ankle

Broken Ankle (Ankle Fracture) Quick Overview

  • A broken ankle is a fracture of one of the bones of the ankle, including the tibia, fibula, and talus.
  • Any crack, break, or chip in the anklebone is considered a fractured ankle, while a sprained ankle is an injury where there is tear or disruption of the ligaments (the fibrous tissue that holds bone to bone in a joint).
  • Broken ankles are caused by stressing the ankle joint beyond the strength of its elements. Ligaments may also tear at the same time an ankle is fractured. Fractures can occur due to rolling the ankle in or out, twisting the ankle side to side, extreme flexing or extending of the joint, or severe force applied to the joint by coming straight down on it as in jumping from a high level.
  • Signs and symptoms of a broken ankle include
    • pain,
    • swelling,
    • bruising,
    • deformities of the bones around the ankle,
    • pale skin around the foot,
    • numbness, or an
    • inability to move the toes.
  • A broken ankle is diagnosed by a history and physical exam, and X-rays may be ordered if needed.
  • Treatment for a broken ankle includes casting, taping, wrapping, booting, or surgery, depending on the type and severity of the fracture.
  • The prognosis for ankle fractures is good to fair. The recovery time for a broken ankle for most patients is 4-8 weeks for the bones to heal, and several months to regain full range of motion of the ankle joint. Severe fractures such as those requiring surgery will take more time to heal.

What is a broken ankle?

Ankle injuries are among the most common of the bone and joint injuries. Often, the degree of pain, the inability to walk, or concern that a bone may be broken is what usually causes people to seek care for an ankle injury. The main concern is whether there is a broken bone vs. an ankle sprain. Frequently it is difficult to distinguish a fracture (broken bone) over a sprain, dislocation, or tendon injury without X-rays of the ankle.

  • The ankle joint is made up of three bones that fit anatomically (articulate) together, the tibia, fibula, and talus (some medical experts also include the calcaneus bone and label the joint as the subtalar joint and consider it part of the ankle):
    • The tibia, the main bone of the lower leg, makes up the medial, or inside, anklebone.
    • The fibula is a smaller bone that parallels the tibia in the lower leg and makes up the lateral, or outside, anklebone.
    • The far ends of both the tibia and fibula are known as the malleoli (singular is malleolus). These malleoli are the lumps of bone that you can see and feel on the inside and outside of the ankle. Together they form an arch or mortise (a recess) that sits on top of the talus, one of the bones in the foot.
  • A fibrous membrane called the joint capsule, lined with a smoother layer called the synovium, encases the joint architecture. The joint capsule contains the synovial fluid produced by the synovium. The synovial fluid allows for smooth movement of the joint surfaces.
  • The ankle joint is stabilized by several groups of ligaments, which are fibers that hold these bones in place. They are the capsule ligament, deltoid ligament, the anterior and posterior talofibular ligaments, and the calcaneofibular ligament. Some of these ligaments may be disrupted if the ankle is fractured.

What do the bones and ligaments of the ankle look like (picture)?

The bones and ligaments of the ankle
Picture of the bones and ligaments of the ankle

What are symptoms of a sprained ankle?

The most common symptom of a sprain is immediate pain at the site of the tear. Other symptoms include:

  • Swelling
  • Bruising
  • Tender to the touch and hurts when it's moved

Symptoms of a more severe sprain include:

  • Hearing and/or feel something tear, along with a pop or snap
  • Extreme pain at first, and the person will not be able to walk or even put weight on the foot.

What are the signs and symptoms of a broken ankle?

Signs and symptoms of ankle injuries and ankle fractures tend to be obvious.

  • Pain is the most common complaint.
    • Sometimes the pain will not come from the exact area of the fracture.
    • The person may experience associated foot fractures (especially on the side of the small toe) or knee that also cause pain similar to ankle pain.
    • It is usually pain in the ankle that stops individuals from walking.
  • Swelling frequently occurs around the ankle.
    • Swelling suggests either soft tissue damage with possible blood around the joint (hemarthrosis) or fluid within the joint itself, most likely blood.
  • A person may see bruising around the ankle joint, although not immediately. The bruising can track down toward the sole of the foot or toward the toes.
  • In severe fractures, there may be obvious deformities of bones around the ankle.
    • Skin may be stretched over an underlying broken bone.
    • Bone may be exposed.
  • If the ankle joint is dislocated, the foot and leg bones will be misaligned and will appear deformed.
  • If people injure nerves or blood vessels that supply the foot, there may be more pain along with pale skin in the foot, numbness, or an inability to move the foot or toes.

What is the difference between a sprained ankle and a broken ankle?

The difference between a broken ankle and a sprained ankle is that a fracture or break in the bone is necessary to have a broken ankle. Any crack, break, or chip in the anklebone is considered a fractured ankle. A sprained ankle is an injury where there is tear or disruption of the ligaments (the fibrous tissue that holds bone to bone in a joint). A severe injury to the ankle can consist of both a fracture and a sprain at the same time. Depending on the type and severity of the fracture or the sprain, the prognosis of a sprain may actually be worse than a fracture.

What causes a broken ankle?

When a person stresses the ankle joint beyond the strength of its elements, the joint becomes injured.

  • If only the ligaments give way and tear, the damage is a sprained ankle.
  • If the ligaments that stabilize the joint are completely disrupted, the bones can come apart and the ankle can become dislocated.
  • If a bone gives way and breaks, the damage is an ankle fracture.
  • Fractured ankles can occur with simultaneous tears of the ligaments. This can happen in several ways:
    • Rolling the ankle in or out
    • Twisting the ankle side to side
    • Extreme flexing or extending of the joint
    • Severe force applied to the joint by coming straight down on it as in jumping from a high level

What are the types of ankle fractures?

The type of ankle fracture classification depends upon the location of the fracture and which bones of the ankle are fractured. There can be one bone injured, or multiple bones injured. The type and severity of the fracture will determine the treatment by the orthopedic surgeon; a classification list is as follows:

Lateral Malleolus Fracture

  • The lateral malleolus is the bump on the outer part of the ankle and is made up of the fibula bone.

Medial Malleolus Fracture

  • The medial malleolus is the bump on the inside of the ankle and is made up of the tibia bone.

Posterior Malleolus Fracture

  • The posterior malleolus is the bony prominence on the back side of the tibia, and is rarely injured on its own.

Bimalleolar Fractures

  • "Bi" means two, so two bones of the ankle are fractured with a bimalleolar fracture.
  • Most commonly the lateral malleolus and the medial malleolus are the bones that are fractured.
  • Bimalleolar fractures often make the ankle joint unstable.

Trimalleolar Fractures

  • "Tri" means three so in a trimalleolar fracture, all three malleoli (medial, lateral, and posterior) bones of the ankle are broken.
  • These are unstable injuries often caused by a large amount of force, disruption of the ligaments, or a dislocation.

Syndesmotic Injury

  • Also called "high ankle sprains."
  • Usually a result of ankle eversion (outward twisting of the ankle joint).
  • May or may not be associated with an actual fracture of the bones of the ankle, but is often treated as a fracture.
  • May involve fracture of the fibula (outer bone in the lower leg) higher up in the calf near the knee (proximal) in severe ankle sprains, also called a Maisonneuve fracture.

There are other names for ankle injuries; however, most will fit into the general types listed above.

What kind of doctor treats a broken ankle?

A broken ankle may be diagnosed by a general practitioner (family doctor, internist, pediatrician), or an emergency medicine doctor in a hospital. The patient may be referred to a podiatrist (foot specialist) or an orthopedic surgeon for the care and further treatment of the broken ankle depending on the severity of the injury or the need for possible surgery.

When to should I contact a health-care professional if I think I may have broken my ankle?

If a person has injured an ankle, contact a doctor or go to an emergency department. Seek medical treatment for an ankle injury in the following situations.

  • The person cannot bear weight on the ankle.
  • The pain remains intolerable despite using over-the-counter pain medications.
  • Home care fails to reduce the pain.
  • The foot or ankle becomes numb, partially numb, or pale.
  • A gross deformity of the ankle bones is present (this may indicate an ankle dislocation)
  • Open wound or bleeding over the injured area
  • Bones or bone fragments visible outside the ankle skin
  • Inability to move the toes
  • Inability to move the ankle
  • Cold or blue foot

How is a broken ankle diagnosed?

A doctor will evaluate the ankle to determine if there is an ankle fracture or if the joint has been damaged sufficiently to become unstable. Joint instability often suggests multiple fractures, a fracture with a ligament injury, ligament injury alone, or dislocation.

The doctor will seek a history of the injury and will ask questions to determine the possible fracture patterns.

  • Where does it hurt now?
  • How long ago did the injury happen?
  • Does the knee, shin, or foot hurt also?
  • How did the injury happen?
  • Did the ankle turn in or out?
  • Did the person hear a crack or a pop?
  • Was the person able to walk immediately after the injury?
  • Can the person walk now?
  • Does the person have any new numbness or tingling in their leg, ankle, or foot?
  • Has the person had previous ankle fractures, sprains, or surgeries on the injured ankle?

The doctor will perform a physical exam, looking for:

  • Evidence of bruising, abrasions, or cuts
  • Swelling, bleeding, and tissue damage
  • Pain, deformities, and the grinding or movement of broken bones of the knee, shin, ankle, and foot
  • Pain, excess looseness of a joint, or complete tear in ligaments
  • Fluid in the joint and joint stability
  • Seeking a pulse and looking for injured arteries
  • Testing sensation and movement in both the ankle and foot
  • Ankle X-rays if a broken bone is suspected; some doctors may try to avoid unnecessary and costly X-rays by following certain guidelines such as the Ottawa ankle rules (see reference 2)
  • X-rays of the knee, shin, or foot depending on where pain is; children may get a comparison X-ray of the uninjured ankle to see subtle changes in growth plates due to injury.

Can I care for a broken ankle at home?

If a person suspects an ankle fracture, call a doctor or go to a hospital's emergency department immediately. Until a person can get to a hospital or doctor's office they may try the following:

  • Stay off the injured ankle to not to injure it further.
  • Keep the ankle elevated to help decrease swelling and pain.
  • Apply cold packs to the injured area to decrease swelling and pain. Do not apply ice directly. Cold packs are effective for the first 24 to 48 hours.
  • Ibuprofen (Advil, Motrin, etc.) is ideal for ankle injuries because it acts as both a pain medicine and a medicine to decrease inflammation.

What is the medical treatment for a broken ankle?

  • Doctors usually place a splint on the injured ankle for a few days to 2 weeks until the swelling decreases around the joint. The type of fracture and the stability of the fractured joint will determine the type of splint (cast or walking boot) that will be used, or whether surgery is needed.
  • Some minor ankle fractures do not require a splint or cast. In these cases the fracture will be managed as an ankle sprain.
    • Because these fractures are very small, they heal well with this management.
    • With any injured ankle, however, a person should not bear weight until advised to do so by a doctor or orthopedist.
  • After the swelling decreases and the patient is reexamined, an orthopedic doctor or a primary care doctor may place a better-fitting cast on the ankle. Depending on the type of fracture, the patient may be placed in a walking cast, which can bear some weight, or the patient may need a non-weight-bearing cast that will require the use of crutches to assist with walking.
  • Depending on the degree of pain, the doctor may prescribe pain medication. The patient should use the pain medication only as needed. Do not drive or operate heavy machinery while using these medications.

What about realignment or surgery to treat a broken ankle?

Fractures that are severely displaced or may involve a dislocation will need to be realigned (reduced) in the emergency department. If the realignment is incomplete or if the underlying injury is severe, surgery is usually needed. If the fracture breaks through the skin (compound fracture), it will usually require surgery to clean the area thoroughly and limit the chance of infection.

Do I need to follow-up with my doctor after a broken ankle?

Follow-up care for an ankle fracture depends on the severity of the fracture. Consultation with an orthopedist is recommended for most fractures. In some instances, a surgeon may need to be consulted, especially if there is any vascular compromise or deformity due to the fracture.

  • The patient may need emergency surgery, next-day follow-up, or follow-up in 1-2 weeks with an orthopedic doctor.
  • The patient may require follow-up with a family doctor.
    • If the patient's injured ankle was splinted on the initial visit, he or she will probably need to have a cast placed on the ankle during the follow-up visit.
    • Recovery time varies depending upon the type of fracture or need for surgery. The average fracture requires 4-8 weeks for the bone to heal.
    • With severe ankle injuries, the doctor may recommend physical therapy for rehabilitation after the acute phase of healing.

What is the recovery time for a broken ankle?

Most simple fractures heal well with immobilization and non-weight-bearing activity. Complex fractures may have good to fair outcomes, depending on the severity of the fracture(s), the effect of rehabilitation on function and the development of arthritis.

  • Patients can expect recovery from most ankle fractures, depending on how severe they are, to take 4-8 weeks for the bones to heal completely and up to several months to regain full use and range of motion of the joint.
  • More severe fractures, especially those requiring surgical repair, will take longer to heal; some may need implanted supports (metal rod or plate and screws) that may be removed later or left in place.
  • Fractures of any type increase the likelihood of developing arthritis in the affected joint. The more severe the fracture, the higher the risk of developing some degree of arthritis.

Can a broken ankle be prevented?

Preventing ankle fractures can be difficult.

  • Many occur as "slip and fall" incidents. Being careful in activities is the best prevention.
  • Proper footwear when participating in sports also may reduce ankle fracture risk.
  • Splints, braces, or taping of a previously injured ankle may decrease the possibility of further injury or fracture.
  • Maintenance of strength of the muscles that stabilize ankle is an important part of prevention of ankle injuries.

REFERENCES:

American Academy of Orthopaedic Surgeons. Ankle Fractures (Broken Ankle). Last Reviewed March 2013.
<>http://orthoinfo.aaos.org/topic.cfm?topic=a00391>

Broomhead A, Stuart P, Validation of the Ottawa Ankle Rules in Australia. Emerg Med;15(2):126-32, 2003

Iskyan, K., MD. "Ankle Fracture." Medscape. Updated Dec 08, 2014.
<http://emedicine.medscape.com/article/824224-overview>

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