Highlights & Basics
- Ankle fractures are commonly a low-energy fracture of either the lateral or medial malleolus, or both, and can include a fracture of the posterior malleolus.
- May be associated with a dislocation of the ankle joint.
- Can be associated with a disruption of the tibiofibular syndesmosis.
- Displaced fractures are commonly treated with an open reduction and internal fixation.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Backslab application: Webril is applied usually overlapping by about 50% to give at least 2 layers of padding under the plaster
Backslab application: the plaster slabs are then applied (2 side supports that wrap around the foot and one posterior support)
Backslab application: an optional layer of Webril over the plaster prevents the tensor bandage or flannel from sticking and allows for ease of removal. The tensor bandage is then applied (some use flannel wrap) with minimal to no tension; it is "just rolled on"
Mortise view of a trimalleolar fracture dislocation with concomitant disruption of the syndesmosis
Mortise view of a trimalleolar fracture after fixation. Note: 2 syndesmosis screws were also used
Lateral view of a trimalleolar fracture after fixation
Citations
Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957-985.[Abstract]
American College of Radiology. ACR Appropriateness Criteria: acute trauma to the ankle. 2020 [internet publication].[Full Text]
Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-1132.[Abstract]
American Academy of Orthopedic Surgeons. Prevention of surgical site infections after major extremity trauma: evidence-based clinical practice guideline. March 2022 [internet publication].[Full Text]
1. Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma. 1996:10:v-ix,1-154.[Abstract]
2. Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957-985.[Abstract]
3. Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005;19:635-639.[Abstract]
4. Hasselman CT, Vogt MT, Stone KL, et al. Foot and ankle fractures in elderly white women. Incidence and risk factors. J Bone Joint Surg Am. 2003;85:820-824.[Abstract]
5. Court-Brown C, McQueen M, Tornetta P 3rd. Ankle fractures. in: Trauma, orthopaedic surgery essentials. Tornetta P 3rd, Einhorn T, eds. Philadelphia, PA; Lippincott Williams and Wilkins: 2006.
6. Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. 2005;19:102-108.[Abstract]
7. Jensen SL, Andresen BK, Mencke S. Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand. 1998;69:48-50.[Abstract]
8. Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957-85.[Abstract]
9. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma. 2006;20:267-272.[Abstract]
10. Greenfield DM, Eastell R. Risk factors for ankle fracture. Osteoporos Int. 2001;12:97-103.[Abstract]
11. Seeley DG, Kelsey J, Jergas M, et al. Predictors of ankle and foot fractures in older women. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res. 1996;11:1347-1355.[Abstract]
12. McGuine TA, Brooks A, Hetzel S. The effect of lace-up ankle braces on injury rates in high school basketball players. Am J Sports Med. 2011;39:1840-1848.[Abstract][Full Text]
13. van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2009;129:227-235.[Abstract]
14. Milne L. Ottawa ankle decision rules. West J Med. 1996;164:67.[Abstract][Full Text]
15. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-32.[Abstract]
16. Advanced Trauma Life Support (ATLS) Manual. 7th ed. American College of Surgeons: 2007.
17. Park SS, Kubiak EN, Egol KA, et al. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma. 2006;20:11-18.[Abstract]
18. Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. 2005;436;216-221.[Abstract]
19. Schock HJ, Pinzur M, Manion L, et al. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br. 2007;89:1055-1059.[Abstract]
20. Koval KJ, Egol KA, Cheung Y, et al. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma. 2007;21:449-455.[Abstract]
21. Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment. EFORT Open Rev. 2018 May;3(5):294-303.[Abstract][Full Text]
22. American College of Radiology. ACR Appropriateness Criteria: acute trauma to the ankle. 2020 [internet publication].[Full Text]
23. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-1132.[Abstract]
24. DeAngelis NA, Eskander MS, French BG. Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures? J Orthop Trauma. 2007;21:244-247.[Abstract]
25. Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and predictors of return to function. J Orthop Sports Phys Ther. 1998;27:276-284.[Abstract]
26. American Academy of Orthopedic Surgeons. Prevention of surgical site infections after major extremity trauma: evidence-based clinical practice guideline. March 2022 [internet publication].[Full Text]
27. American Academy of Orthopaedic Surgeons. Appropriate Use Criteria: prevention of surgical site infection after high energy extremity trauma. March 2022 [internet publication].[Full Text]
28. British Association of Plastic, Reconstructive, and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA). Standards for the management of open fractures. 2020 [internet publication].[Full Text]
29. National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. 2016 [internet publication].[Full Text]
30. Petrisor BA, Poolman R, Koval K, et al. Management of displaced ankle fractures. J Orthop Trauma. 2006;20:515-518.[Abstract]
31. Schepers T, de Vries MR, van Lieshout EM, et al. The timing of ankle fracture surgery and the effect on infectious complications; a case series and systematic review of the literature. Int Orthop. 2013;37:489-494.[Abstract][Full Text]
32. Pakarinen H. Stability-based classification for ankle fracture management and the syndesmosis injury in ankle fractures due to a supination external rotation mechanism of injury. Acta Orthop Suppl. 2012;83:1-26.[Abstract]
33. Kurmis AP, Kurmis TP, O'Brien JX, et al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012;94:815-823.[Abstract]
34. British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons. Open fractures. December 2017 [internet publication].[Full Text]
35. Smit L, Boyle M. Management of ankle injuries in the prehospital environment - a review of the literature. Australas J Paramed. 2013;10:6.
36. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764.[Abstract]
37. Rhee P, Nunley MK, Demetriades D, et al. Tetanus and trauma: a review and recommendations. J Trauma. 2005;58:1082-1088.[Abstract]
38. Kortekangas T, Haapasalo H, Flinkkilä T, et al. Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial. BMJ. 2019 Jan 23;364:k5432.[Abstract][Full Text]
39. Donken CC, Al-Khateeb H, Verhofstad MH, et al. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev. 2012;(8):CD008470.[Abstract][Full Text]
40. Slobogean GP, Marra CA, Sadatsafavi M, et al; Canadian Orthopedic Trauma Society. Is surgical fixation for stress-positive unstable ankle fractures cost effective? Results of a multicenter randomized control trial. J Orthop Trauma. 2012;26:652-658.[Abstract]
41. Hoelsbrekken SE, Kaul-Jensen K, Mørch T, et al. Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial. J Orthop Trauma. 2013;27:633-637.[Abstract]
42. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009;66:279-284.[Abstract]
43. Li ZH, Yu AX, Guo XP, et al. Absorbable implants versus metal implants for the treatment of ankle fractures: a meta-analysis. Exp Ther Med. 2013;5:1531-1537.[Abstract]
44. Hu YL, Yuan WQ, Wang LF, et al. A prospective randomized trial of poly-DL-lactic acid absorbable and metallic screws for treatment of syndesmotic disruptions [in Chinese]. Nan Fang Yi Ke Da Xue Xue Bao [J South Med Univ.]. 2010;30:2360-2362.[Abstract]
45. Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop. 2012;36:1199-1206.[Abstract][Full Text]
46. Kortekangas T, Savola O, Flinkkilä T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015;46:1119-1126.[Abstract]
47. Laflamme M, Belzile EL, Bédard L, et al. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015;29:216-223.[Abstract]
48. Hancock MJ, Herbert RD, Stewart M. Prediction of outcome after ankle fracture. J Orthop Sports Phys Ther. 2005;35:786-792.[Abstract]
49. Shah NH, Sundaram RO, Velusamy A, et al. Five-year functional outcome analysis of ankle fracture fixation. Injury. 2007;38:1308-1312.[Abstract]
50. McKeown R, Ellard DR, Rabiu AR, et al. A systematic review of the measurement properties of patient reported outcome measures used for adults with an ankle fracture. J Patient Rep Outcomes. 2019 Dec 17;3(1):70.[Abstract][Full Text]
51. Tejwani NC, McLaurin TM, Walsh M, et al. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am. 2007;89:1438-1441.[Abstract]
52. Egol KA, Tejwani NC, Walsh MG, et al. Predictors of short-term functional outcome following ankle fracture surgery. J Bone Joint Surg Am. 2006;88:974-979.[Abstract]
53. Dehghan N, McKee MD, Jenkinson RJ, et al. Early weightbearing and range of motion versus non-weightbearing and immobilization after open reduction and internal fixation of unstable ankle fractures: a randomized controlled trial. J Orthop Trauma. 2016;30:345-352.[Abstract]
54. Bhandari M, Sprague S, Hanson B, et al. Health-related quality of life following operative treatment of unstable ankle fractures: a prospective observational study. J Orthop Trauma. 2004;18:338-345.[Abstract]
55. Obremskey WT, Dirschl DR, Crowther JD, et al. Change over time of SF-36 functional outcomes for operatively treated unstable ankle fractures. J Orthop Trauma. 2002;16:30-33.[Abstract]
56. Nilsson G, Jonsson K, Ekdahl C, et al. Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Musculoskelet Disord. 2007;8:127.[Abstract][Full Text]
57. Ganesh SP, Pietrobon R, Cecilio WA, et al. The impact of diabetes on patient outcomes after ankle fracture. J Bone Joint Surg Am. 2005;87:1712-1718.[Abstract]
58. Brown OL, Dirschl DR, Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001;15:271-274.[Abstract]
59. Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg. 2011;131:879-883.[Abstract][Full Text]
60. Walsh EF, DiGiovanni C. Fibular nonunion after closed rotational ankle fracture. Foot Ankle Int. 2004;25:488-495.[Abstract]
61. Thomas G, Whalley H, Modi C. Early mobilization of operatively fixed ankle fractures: a systematic review. Foot Ankle Int. 2009;30:666-674.[Abstract]
62. Lin CW, Donkers NA, Refshauge KM, et al. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012;(11):CD005595.[Abstract][Full Text]
63. Smeeing DPJ, Houwert RM, Briet JP, et al. Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial. Eur J Trauma Emerg Surg. 2020 Feb;46(1):121-130.[Abstract][Full Text]
64. Moseley AM, Beckenkamp PR, Haas M, et al. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015;314:1376-1385.[Abstract][Full Text]
65. Nilsson GM, Jonsson K, Ekdahl CS, et al. Effects of a training program after surgically treated ankle fracture: a prospective randomised controlled trial. BMC Musculoskelet Disord. 2009;10:118.[Abstract][Full Text]
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