Ankle joint is the most used joint in human body. Ankle joint is formed by tibia, fibula, talus and calcaneal bone. Body weight is carried to the ground through ankle joint. Once the ankle joint is fractured, the joint become unstable. Individual suffering with ankle joint fracture or broken ankle is unable to put weight on injured foot because of pain and unstable ankle joint. Ankle Joint Fracture or broken ankle is often seen following work or automobile accident. Ankle joint fracture or Broken ankle joint is also observed following sports injury or wrong twist and turn of ankle joint.
What can Cause an Ankle Joint Fracture or a Broken Ankle?
Direct Blow or Impact to the Ankle Joint can Cause Ankle Joint Fracture-
- Auto Accident
- Work Accident
- Sport Injury- Fracture of the ankle joint is common in sports like football, soccer, baseball or wrestling.
Ankle Joint Fracture Caused due to Wrong Twist and Turn of Ankle Joint-
- Work Accident- Fracture of the ankle joint is common due to tripping or twisting the ankle during manual work.
- Sports Injury- Sports like Tennis and Rugby can cause Ankle Joint Fracture or broken ankle.
What are the Different Types of Ankle Joint Fracture or Broken Ankle?
- Hairline Fracture or Stress Fracture of Ankle Joint - Hairline Ankle Joint Fracture is also known as stress fracture of the ankle. Hairline fracture of the ankle joint or stress fracture of the ankle joint is mostly seen with medial and lateral malleolus. Stress fracture of medial and lateral malleolus is a non-displaced ankle fracture and maintains intact anatomical structure. Hairline ankle fracture does not cross entire thickness of the bone. Hairline ankle joint fracture is a partial (superficial) crack without any separation of bones.
- Non-Displaced Ankle Joint Fracture (Transverse Fracture) - Non displaced ankle joint fracture is a full thickness crack in the bone without any separation or slide of the two ends of fractured ankle bone. Adjacent bone maintains anatomical position without separation. Such non-displaced ankle fracture is also known as transverse fracture. Blood supply to fractured end is maintained normal which prevents avascular necrosis. Non-displaced ankle fracture is often observed in lower end of tibia and fibula following slip and fall.
- Partial Displaced Ankle Joint Fracture- Proximal (upper) and distal (lower) end of broken ankle bone are partially displaced resulting in sideway dislodgment of one or both the fractured bones. Separation is never complete. 10 to 90% of the fractured surface of the two ends maintains contact. Partial displaced ankle fracture causes deformity like joint swelling and mal-alignment of the ankle joint. Blood supply to adjacent fractured bone is interrupted and may result in avascular necrosis if not treated within 6 to 8 hours following injury. Partial displaced ankle joint fracture is observed with lower end of tibia, talus and calcaneal bone.
- Completely Displaced Ankle Joint Fracture- Completely displaced ankle fracture is often associated with multiple fragments of bones of ankle joint. Fragmented complete displaced fracture of the ankle is seen following severe direct impact over ankle joint by heavy objects. Proximal (upper) and distal (lower) bones of the fractured sites are completely separated and does not maintain any contact. Blood supply to the adjacent fractured bones is interrupted resulting in avascular necrosis.
- Compound Fracture of Ankle Joint- Compound fracture is a complete displaced fracture of the ankle with open wound. The fragment of the ankle bone is exposed to atmosphere through an open skin wound. Infection and avascular necrosis is common complication.
Classification of Ankle Joint Fracture or Broken Ankle
- Fracture of Medial Malleolus – Medial malleolus is a medial (inner) side extension of lower end of tibia bone. Medial malleolus is one of the skeletal elements of the medial section of superior ankle joint. Medial malleolus fracture could be hairline, non-displaced or partially displaced ankle fracture. Fracture of the ankle results from direct impact or twist and turn of the ankle joint.
- Fracture of Posterior Malleolus- Posterior malleolus is a posterior section of lower end of tibia. Fracture of posterior malleolus is less common since Achilles tendon protects posterior segment of tibia. Fracture type is mostly stress fracture or non-displaced fracture of posterior malleolus.
- Fracture of Lateral Malleolus – Lateral malleolus is a lower end of fibula and part of lateral section of superior ankle joint. Lateral malleolus fracture is seen following direct impact of lower end of fibula and twist or turn of ankle joint. Fracture type is hairline, non-displaced, displaced or compound fracture of lateral malleolus.
- Bi-Malleolus Fracture- Bi-Malleolus fracture is rare but seen after automobile accident or work accident.
- Fracture of Talus Bone- Talus bone is protected at inner (medial) and outer (lateral) side by medial and lateral malleolus bone. Severe impact caused by heavy object results in multiple fragmented completely displaced fracture or compound fracture of talus bone. Twist and turn of ankle joint causes hairline or incomplete fracture of talus bone.
- Fracture of Calcaneal Bone- Calcaneal bone forms an inferior ankle joint with talus bone known as subtalar joint. Calcaneal bone is often fractured as a result of direct impact. Fracture type is hairline, incomplete displaced, completely displaced or compound fracture of the calcaneal bone.
- Cartilage Damage- Fracture of ankle joint if extended in to ankle joint then the injury could damage cartilage. Cartilage damage if not treated appropriately then condition may advance to arthritis.
- Pott's Fracture- Pott's fracture consists of fracture of lower end of tibia and dislocations of the distal tibia-fibula joint.
- Pilon Fracture- Pilon fracture includes distal tibial fracture, fracture of talus and subluxation of tibio-talus joint. Fall from height often causes Pilon fracture as talus is forced into lower surface of tibia.
- Maisonneuve Fracture- Fracture includes fracture of fibula, medial malleolus and tear of deltoid ligament.
- Snowboarder's Fracture- Fracture of lateral portion of talus is caused by forced dorsiflexion.
What are the Symptoms of Ankle Joint Fracture or Broken Ankle?
Symptoms of Ankle Joint Fracture or Broken Ankle #1: Ankle Joint Pain-
- Duration of Ankle Pain- Ankle pain as a result of fracture of the ankle joint is termed as acute if it lasts less than 3 months, and is termed as chronic ankle pain if it lasts more than 3 to 6 months.
- Character of Ankle Pain- Ankle Pain as a result of ankle joint fracture is felt like stabbing and shooting pain.
- Intensity of Ankle Pain- Pain in the ankle as a result of fracture of the ankle joint is continuous and severe. Ankle joint movement causes very severe pain.
Symptoms of Ankle Joint Fracture or Broken Ankle #2: Sensory Nerve Deficiency-
- Compound and displaced fracture of ankle joint causes sensory nerve injury around ankle joint.
- Sensory nerve injury around the ankle joint is either temporary or permanent depending on nerve damage.
- Initial sensory deficiency symptoms are tingling and later it is numbness. Symptoms like tingling and numbness are observed in feet and toes.
Symptoms of Ankle Joint Fracture or Broken Ankle #3: Weakness in Foot and Toes-
- Motor nerve injury around ankle joint causes weakness of muscles supporting movements of feet and ankle.
- Weakness may be permanent or temporary depending on nerve injury.
- Symptoms often subside if nerve injury recovers.
- During recovery phase of Ankle Joint Fracture, physical therapy and muscle exercise should be continued to prevent muscle atrophy and permanent weakness of the ankle joint.
What are the Signs of Ankle Joint Fracture or Broken Ankle?
Signs Ankle Joint Fracture or Broken Ankle #1: Restricted Ambulation
- Ambulation such as walking is restricted because of severe intractable pain and unstable ankle joint. Patient is unable to stand or walk using injured ankle.
- Ankle pain is less severe if crutches, walker or wheel chair is used for ambulation.
Signs Ankle Joint Fracture or Broken Ankle #2: Tenderness
- Ankle joint is extremely tender.
- Deep palpation of ankle joint results in severe pain lasting for several hours.
Signs Ankle Joint Fracture or Broken Ankle #3: Ankle Deformity
- Ankle joint deformity is observed on inspection.
- Deformity is secondary to displacement of fractured segment, which protrude out of ankle joint.
- Deformity of ankle joint is also seen following compound fracture. Fractured bone bulges out through ruptured skin.
Signs Ankle Joint Fracture or Broken Ankle #4: Bruising and Laceration of the Skin
- Skin bruising and laceration is seen over the ankle joint.
- Bleeding following ankle joint fracture is either secondary to capillary oozing from injured bones and tear of blood vessels close to the joint.
- Blood is collected and spread around ankle joint.
- Direct impact of ankle joint causes bleeding within subcutaneous tissue. Bleeding is caused by injury or tear of subcutaneous blood vessels from impact.
- Bruising is subcutaneous spread of blood either from subcutaneous bleeding or spread of blood from fractured ankle joint bones.
- Underneath the bruised skin, may be a fluctuating large hematoma. Hematoma (blood clot) is a soft fluctuating swelling surrounds the fracture ankle joint.
- Lump or Swelling
- Lump is observed following partial or complete ankle joint fracture.
- Soft fluctuating swelling is secondary to blood clot in ankle joint or subcutaneous tissue.
- Hard lump is caused by end of fracture bone protruding through subcutaneous tissue and skin.
Signs Ankle Joint Fracture or Broken Ankle # 5: Signs of Nerve Injury
- Sensory Nerve Injury- Touch, temperature and pain sensation are reduced or lost.
- Motor Nerve Injury- Power, tone and coordination of foot and toe muscles are below normal strength or absent.
Signs Ankle Joint Fracture or Broken Ankle #6: Inability to Walk or Ambulate
- Patient following ankle joint fracture is unable to ambulate or walk because of pain and joint instability.
Investigations to Diagnose Ankle Joint Fracture or Broken Ankle
X-Ray to Evaluate Ankle Joint Fracture-
- Antero-posterior and lateral view of the ankle joint shows partial or complete hip joint fractures.
- Small Hairline or Stress Ankle Joint Fracture is difficult to diagnose with plain x-ray.
MRI to Evaluate Ankle Joint Fracture-
- Diagnosis of all types of Ankle Joint Fracture.
- MRI radiological study is performed to rule out Hairline or Stress Ankle Joint Fracture.
- Diagnose multiple fractures causing compound fracture of ankle joint bones.
- Evaluate hematoma located within ankle joint or subcutaneous tissue.
- MRI study also indicated to evaluate nerve injuries.
CT Scan to Evaluate Ankle Joint Fracture-
- CT Scan is an alternative radiological study to MRI.
Ultrasound Study to Evaluate Ankle Joint Fracture-
- Evaluate displaced and compound fracture of Ankle Joint.
- Evaluate hematoma intra-articular (within joint) or subcutaneous by ultrasound depth study.
- Evaluate peripheral ankle joint nerve injuries.
Bone Density Test-
- Bone density study is performed to rule out osteoporosis as a cause of Ankle Joint Fracture.
- Study is performed to rule out-
- Decreased bone mass.
- Brittle bone.
- White Blood Cell Count Examination (WBC)- WBC study is performed to rule out infection. WBC count is increased in infection.
- Hemoglobin (Hb)- Hb count is reduced in anemia caused by bleeding and loss of blood following injury.
Treatment of Ankle Joint Fracture or Broken Ankle
Indication for Conservative Treatment for Ankle Joint Fracture or Broken Ankle-
- Hairline Fracture of the Ankle
- Non-Displaced Fracture of the Ankle
Choice of Conservative Treatment for Ankle Joint Fracture or Broken Ankle
- Ice and Cold Therapy is helpful for fractured ankle. Cold therapy is used to treat ankle joint swelling and reduce bleeding
- Ace Bandage or Crape bandage
- Ankle Braces and Cast
- Pain Medications to control the pain on account of fractured ankle
- Physical Therapy
- Close Reduction of Fracture to treat fractured ankle
Medication for Ankle Joint Fracture or Broken Ankle
- NSAIDs- For inflammation and pain around the fractured ankle.
- Opioids- For ankle pain.
- Muscle Relaxants- For ankle muscle spasm.
- Antibiotics- For infections around the fractured ankle.
- Calcium and Vitamin D- For deficiency and osteoporosis.
Physical Therapy (PT) for Ankle Joint Fracture or Broken Ankle
- Ankle Joint Stretching- Physical therapy is directed to stretch the ankle joint to treat non-displaced fracture of the ankle joint. Physical therapy is continued after surgical treatment of fractured ankle to prevent atrophy and weakness of the calf and foot muscles.
- Cold and Ice Therapy- Cold therapy is used to treat joint swelling and reduced bleeding.
- Ankle Muscle Strengthening- Physical therapy following surgery for fractured ankle is used to strengthen muscles supporting ankle joint.
- Ankle Joint Stiffness- Aggressive physical therapy is performed following ankle joint healing to prevent ankle joint stiffness. Joint movements are performed using passive and active exercises.
Interventional Pain Therapy for Ankle Joint Fracture or Broken Ankle
- During Healing of Ankle Fracture- Interventional pain therapy is not useful during healing of fractured ankle joint.
- After Healing of Ankle Fracture- Cortisone and local anesthesia injections are performed to assist physical therapy after wound is healed.
- Chronic Ankle Pain Not Responding To Surgery and Opioid- Patient is treated with spinal cord stimulator.
Surgery for Ankle Joint Fracture or Broken Ankle
Indication for Surgery to Treat Fractured Ankle
- Partial Displaced Fracture of the Ankle Joint
- Complete Displaced Fracture of the Ankle Joint
- Non-Union Fracture of Ankle Joint
- Compound Fracture Ankle Joint
- Cartilage Damage
Choice of Surgical Treatment for Ankle Joint Fracture or Broken Ankle
- Wiring- Medial and lateral malleolus fracture is treated with wiring.
- Insertion of Nail- Fracture of lateral malleolus is treated with placing the nail to maintain normal anatomical position of fractured segments.
- Plate and Screws- Fracture of lower end of tibia, fibula and calcaneal bone is treated with plate and screws.
- Rod Inside Bone- Compound fracture and displaced fracture of fibula and tibia is treated with rod and if necessary screws and plates.
- Bone Grafting- Displace and compound fracture associated with bone necrosis is treated with bone graft.
- Total Ankle Joint Replacement- Surgery is difficult and yet not well established. Surgery is useful to treat ankle joint osteoarthritis caused by ankle joint fracture.
Surgery For Ankle Fracture
Surgical Complications for Ankle Joint Fracture or Broken Ankle
- Infection may follow surgery for fractured ankle because of faulty equipment or not following postop instruction by patients.
- Treatment of infection following surgery for fractured ankle becomes difficult if patient had surgery and metal instruments are used to stabilize fracture.
- Bleeding could be major or minor. Patient may be taken for revision of surgery to stop bleeding.
Thrombosis and Embolism Following Surgery For Fractured Ankle-
- Blood clots (Thrombosis) are often formed in leg veins and arteries.
- Pieces of blood clot (emboli) may travel through blood vessels to distant organ.
Soft Tissue Damage Following Surgery for Fractured Ankle or Broken Ankle-
- Surgery may damage blood vessels, tendons, or nerves.
- Bone healing may be inadequate after surgery for fractured ankle or broken ankle. Patient may need revision of surgery.
- Fracture of bones if extends into ankle joint then cartilage is often damaged. Cartilage damage may cause arthritis.
Pain Secondary to Instrumentation-
- Instrumentation surgery involves insertion of plates, screw or rod.
- In few cases instrumentations causes severe pain.
- Pain may not respond to pain therapy and in many cases instruments have to be removed.
Prognosis and Recovery Following Ankle Joint Fracture or Broken Ankle
Prognosis and recovery time following fracture of ankle depends on the extent of injury. Healing of fracture of fibula may take 4 to 6 weeks. On the contrary healing of fracture of tibia and talus may take longer than 8 weeks. Healing time of fracture of all three ankle bones may take 8 to 10 weeks. Recovery time to resume normal activities following fractured ankle or broken ankle may depend on the muscle weakness and atrophy. The ankle braces or plaster restricts ankle movements resulting in inactive ankle muscles. Inactive ankle muscles became atrophied and weak. Following healing of fractured ankle bones, patient needs aggressive physical therapy for 4 to 6 weeks under supervision of certified physical therapist. Thus patient may resume normal activities after 4 to 6 weeks following complete healing of the ankle joint fracture. In reality the entire period required to heal the ankle fracture and recover to normal ankle muscle activities could be 16 to 20 weeks. Prognosis for fractured ankle or broken ankle also depends on residual pain. Few patients may feel mild to moderate pain for several months with twist and turn of ankle joint.
Other Complications in Ankle Joint Fracture or Broken Ankle
- Compartmental syndrome is caused by inadequate blood supply.
- Blood supply is strangulated because of increased pressure with and outside the ankle joint following accident.
- Increased pressure could be secondary to blood clot and tissue edema. Lack of blood supply causes tissue necrosis.
- Delay of treatment can lead to loss of function of the ankle and foot.