Ankle fracture (ankle joint fracture)

An ankle fracture (colloquially ankle fracture) is the partial or complete fracture of the fibula in the area of the ankle joint. Such an injury usually also results in soft tissue damage, which means that a broken foot can be very painful.

In this article we would like to inform you about the most important questions concerning ankle fractures:

An ankle fracture is one of the most common fractures of the foot. About 85% of this type of fracture is caused by a dislocation, which is often caused by a misstep or a fall. In comparison, only about 10% of all fractures occur in the context of a traffic accident and about 4% of fractures are caused by direct force. In most cases, a simple twisting of the foot inwards or outwards is the cause.

Almost anyone can be affected by an ankle fracture - regardless of age. For those who are active in sports or competitive athletes, the increased stress per se also carries an increased risk of an ankle fracture. Twisting an ankle (twisting or supination trauma) while running, jogging or other sporting activities is one of the most common accidents in everyday life.

Possible causes of an ankle fracture can be:

• Twist, Misstep
  The causes are usually uneven floors that lead to tripping or slipping when running or jumping. A slippery surface such as black ice or autumn leaves can be the trigger. But in the worst case, coordination problems can also lead to an ankle injury.

• Fall
  An ankle fracture can also be the result of a fall - even from a low height.

• Road accident
  In car accidents, due to the position of the foot and leg in the passenger compartment, a pilon tibial fracture (fracture of the tibia bone), a special form of ankle joint fracture, often occurs.

• Direct impact of force
  Direct force caused by a blow or impact (impact trauma) - e.g. in accidents at work - can also cause an ankle fracture. However, this form only accounts for 3.9 % of all ankle fractures.

Ankle fractures are divided into three classes depending on where they occur: Weber A fracture, Weber B fracture and Weber C fracture. If both the medial and lateral malleolus are broken, this is also called a bimalleolar fracture. Other special forms are the trimalleolar fracture, the pilon-tibial fracture and the Maisonneuve fracture.

ABC Fractures according to the Weber Classification

Ankle fractures can be divided into different medical classifications. Such a classification provides information on how severe the injury is and which surgical treatment options result from it.

Fractures are often classified anatomically according to the Weber classification, depending on the height of the fibula fracture in relation to the syndesmosis (ligament structure between the fibula and tibia). The Weber classification is one of the most common classifications, with A representing the lowest degree of injury and C the highest. The most common fracture is the Weber B fracture.

• The Weber A fracture describes a break at the lower end of the fibula without further injury to the syndesmosis ligament. The ankle joint fork remains stable.
• A Weber B fracture is a fracture of the fibula at the anatomical level of the syndesmosis ligament. This ligament holds the calf and tibia together. It can be involved in this injury and then leads to instability between the two bones, which requires treatment.
• In the Weber C fracture, the fibula breaks above the ankle joint. A tear of the syndesmosis ligaments and thus an unstable ankle fork must always be assumed.

Dr. Gottlieb:

"Basically, there are different forms of ankle fractures or ankle injuries. One can quantify the severity of the fracture with so-called classifications. The Weber classification is one of them. Less common is the Lauge-Hansen classification, which is based on the position of the foot and the direction of movement at the time of the accident."

Special forms of ankle fracture

Another rather rare form of ankle fracture is the pilon tibial fracture. This is a fracture of the tibia bone that often occurs in car accidents.

Another special type of ankle fracture is the Maisonneuve fracture. In this rare dislocation fracture, the entire syndesmosis (ligament structure) from the ankle joint up to the knee is torn. The fibula is broken very high up in this fracture, often close to the knee joint. In addition, a complete tear of all the inner ligaments or the inner ankle is diagnosed. Here, too, the ankle joint is unstable and should be surgically stabilised.

Dr. Gottlieb:

"In an ankle injury, the anterior syndesmosis (ligament structure between the calf and tibia) tears first. Then the outer ankle breaks. Then the posterior syndesmosis possibly even tears off with one bone in one piece. If even more energy is then applied to the rotational fracture, the inner ankle also breaks. This is called a trimalleolar ankle fracture, i.e. the highest form of twisting trauma in the form of a Weber C-fracture."

Basically, a distinction is made between sure and uncertain symptoms of an ankle fracture. Local pain or swelling are not yet a sure sign of a fracture.

Evident signs are:

• Obvious malposition of the foot (visible from the outside)
• Parts of the bone protrude through the skin to the outside (open fracture)
• Pathological mobility: A mobility in places where there is otherwise none. There is an extent of movement beyond what is normal.

Unsafe signs are:

• Local pain
• Swelling of the affected area
• Bruising (haematoma) around the inner and outer ankle
• Restricted mobility
• Reduced usability of the foot

Soft tissues and ligaments of the foot (syndesmosis) or articular cartilage are often injured as concomitants of an ankle fracture. In addition to soft tissue damage, compartment syndrome is a common accompanying injury.

An immediate risk in an accident is, for example, compartment syndrome. Severe injuries such as the pilon tibial fracture are usually associated with such a concomitant injury. In addition, ligament injuries can cause instability, which leads to cartilage wear. As a result, cartilage damage is among the other sequelae. Arthrosis can occur as a possible long-term consequence of an ankle fracture.

In the case of ankle complaints, Dr Gottlieb will first carry out a clinical and manual examination. If a fracture is suspected, X-rays of the ankle joint are taken from different directions. Often the entire lower leg is also x-rayed, because it is not uncommon for there to be several fractures or injuries. The examination methods depend on the severity of the injury. A computer tomography (CT) or magnetic resonance imaging (MRI) may be necessary. If necessary, the blood vessels are also examined with an ultrasound examination (sonography), because vessels or nerves can be affected in severe injuries.

The treatment required basically depends on the type of fracture, the extent of the injury and the stability of the joint. This can vary greatly from case to case.

When does conservative therapy make sense?

Not all ankle fractures require surgery. In the case of a closed Weber A or Weber B fracture with an undisplaced fracture and without syndesmosis injury, conservative (non-surgical) treatment may also be sufficient. Conservative therapy includes immobilisation in a lower leg cast or in an orthosis (splint for relief and stabilisation) for about 6 weeks. Afterwards, the strain after an ankle fracture can be gradually increased within the framework of physiotherapy. With the help of targeted physiotherapy, it is usually possible to switch to full weight-bearing after about 4 to 6 weeks.

In these cases, the foot surgeon advises surgical treatment

In the case of unstable and displaced fractures or the desire to be able to put weight on the foot again as quickly as possible, the foot surgeon Dr Tonio Gottlieb recommends surgical treatment. In an operation, the ankle joint is brought into the correct position (reduced) and the fracture is fixed with screws and plates.

The aim of the operation is to fix the joint in a normal position as long as possible until the surgical area has completely healed. Appropriate implants (screws and plates) also protect the bones and the patient can usually put weight on the foot more quickly. In some cases, an external fixator (an external holding device used to immobilise fractures) must be used. This is often used for pilon tibial fractures because the first phase of treatment is to wait until any compartment syndrome subsides.

Dr. Gottlieb:

"With an operation, I can promise that the fracture will heal faster and the foot will be able to bear weight again sooner. An operation also has the advantage that the risks of arthrosis are reduced. By fixing the fracture with screws and plates, you stabilise the joint and thus reduce the risk of arthrosis later on."

As a rule, the healing time of an ankle fracture is four to six weeks, in exceptional cases eight weeks.