Medial Malleolus Fracture: Causes, Symptoms, Treatment, Recovery Time, Diagnosis

The lower leg has two bones, tibia on the inner side and fibula on the outer side. Both the bones end with a bump on inner and outer side known as medial and lateral malleolus. Medial malleolus fracture when caused by break in the bony structure results in bump on inner side of ankle. The bump or swelling following ankle joint or medial malleolus fracture is located at the lowermost part of tibia on inner side of ankle joint. Such fracture of ankle joint is also called as broken ankle or medial (inner) ankle fracture. Medial malleolus is a part of ankle joint and lower end of the lower leg bone known as tibia. Medial malleolus bone is easily felt with hands on the inner side of the ankle. Medial malleolus is a part of ankle joint and ankle fracture is common with incidence of 174 cases per 100,000 adults per year.¹

The way in which the bone breaks defines the types of medial malleolus fracture. Medial malleolus fracture is often a part of other injuries or fractures of other bones, while sometimes it can also be an isolated fracture. Ankle fractures are one of the commonest fractures of the lower limbs and about 9% of all fractures. Sometimes, the medial malleolus may get injured and develop a crack but the bones do not move apart, which is called hairline fracture or stress fracture of medial malleolus. There are cases published that suggests Achilles tendon fracture can be associated with fracture of medial malleolus bone.² Short healing and recovery time is observed in patient who had early operative intervention.³

1. Hairline Fracture of Medial Malleolus

1. Transverse Fracture
2. Oblique Fracture
3. Vertical Fracture

2. Non-Displaced Medial Malleolus Fracture

1. Transverse fracture
2. Oblique Fracture
3. Vertical Fracture

3. Displaced Medial Malleolus Fracture

4. Avulsion Fracture of Medial Malleolus

5. Comminuted Fracture of Medial Malleolus

6. Compound Fracture of Medial Malleolus

1. Hairline Fracture of Medial Malleolus – Hairline fracture is crack in the superficial layer of bone. Bone does not break into fragments. Hairline fracture is also known as stress fracture. Healing takes short time.

   Types of Hairline Fracture of Medial Malleolus:-

   • Transverse Fracture- It is a horizontal break in the bony prominence or medial malleolus.
   • Oblique Fracture- In this, the break is oblique at the corner of the medial malleolus and is usually due to rotational injury and may also be associated with injury to the fibula.
   • Vertical Fracture- Vertical medial malleolus fracture occurs due to a vertical break in the bone and can also affect the main part of the ankle joint.

2. Non-Displaced Medial Malleolus Fracture- The crack in bone extends through entire thickness of bone. The fracture fragments are aligned and not separated.

   Types of non-displace fracture-

   1. Transverse fracture
   2. Oblique fracture
   3. Vertical fracture

3. Displaced Medial Malleolus Fracture- The crack in bone extends through entire thickness of the bone. The two fractured fragments are separated.

4. Avulsion Fracture of Medial Malleolus – Ankle joint is supported by several ligaments and achilles tendon. Avulsion fracture of medial malleolus bone is associated with injury or tear of the ankle joint ligament and achilles tendon. In most cases the bone fragment is fractured with tear in ligament that is attached to bony fragments.

5. Comminuted Fracture – In this, the fracture of medial malleolus results in multiple breaks in the bones. Multiple fractured fragments may scatter (displaced) or align together (non-displaced).

6. Compound Fracture of Medial Malleolus – Fracture is known as compound fracture when fractured bone is exposed to atmosphere because of deep cut in skin and subcutaneous tissue. Compound fracture may result in comminuted or displaced bone fragments.

• Loss of weight
• Osteoporosis
• Chronic diabetes
• Obesity
• Malnourishment
• Age- Elderly individual frequently fall because of diseases affecting balance that results in frequent fall.

1. Osteoporosis
2. Excess stress on ankle joint
3. Injuries

1. Domestic fall
2. Car accident
3. Work Injury
4. Sports Injury

Medial malleolus fracture or ankle fracture is more common in young men and older women.

1. Osteoporosis- Osteoporosis is a disease results in decrease concentration of calcium. Overuse of ankle joint or over twist of foot and ankle can cause fracture of medial malleolus.
2. Excessive Stress on Ankle Joints- Regular Long distance running or walking adds stress on ankle joint that results in uncoordinated joint movement. Such imbalance joint activity causes transmission of upper body weight through the joint and may result in medial malleolus stress fracture.⁴
3. Injuries-

1. Domestic Fall- Domestic fall is caused by tripping on carpet or staircase, slipping on ice outside house in driveway or fall following stepping on slippery oily surface.
2. Car Accident– Car accident resulting in head-on collision causes inward impact of front end of car. The left foot resting on floor or right foot on accelerator gets impacted and jammed that results in forceful rotation, hyper flex or hyper extended ankle joint. Such joint movement may cause fracture of medial malleolus.
3. Work Injury– Some of the causes of medial malleolus fracture are also related to direct blow to the ankle joint or its inner side of ankle joint while at work by moving object. Such direct impact causes fracture of medial malleolus. Sometime repeated movement of ankle joint while at work can cause stress fracture of medial malleolus.
4. Sports Injury- Sports that involve sudden twisting and turning of lower leg and foot can easily cause injury of ankle joint that may result in a medial malleolus fracture. Most medial malleolus fracture occurs in individual who are participating in professional contact sports.

Symptoms observed following medial malleolus fracture are:-

1. Pain
2. Bruising
3. Stiff Ankle joint
4. Restricted range of ankle joint movement
5. Joint tenderness and swelling
6. Ambulation difficulties

1. Pain- Pain is localized at around medial malleolus or inner side of the ankle joint. Pain may be worse on turning the ankle inwards or outwards with difficulty in standing or walking. Following an injury, pain and swelling of the area is the commonest symptom of medial malleolus fracture. Symptom like pain following medial malleolus fracture develops over few days when fracture is caused due to repeated stress that results in stress fracture. The pain caused by fracture of medial malleolus is felt around the ankle joint but pain of higher intensity is localized over medial side. Initially, the symptoms of medial malleolus fracture due to repeated injuries or stress are noticeable after activity or exercise. Pain is extremely severe immediately following injury that results in displaced, comminuted or compound fracture.
2. Bruising- Bruising is a sign of spread of blood under the skin. The twist and turn of ankle joint results in soft tissue trauma as well as fracture of medial malleolus. The soft tissue trauma causes bleeding under the skin. The bleeding follows collection of blood known as hematoma under the skin, subcutaneous tissue and muscles. The blood that is spread in subcutaneous tissue infiltrate into dermis section of skin and causes purple discoloration of skin. The skin thus looks purple and condition is known as bruises.
3. Stiff Ankle Joint- However, over a period of time, pain may worsen and may be present even after low impact activities like walking and eventually even at rest. The ankle may seem stiff and some swelling may also be noticed.
4. Restricted Range Of Joint Movement- Range of movements of ankle joint is restricted because of pain and joint malfunction secondary to fractured segment interfering with joint movement. Pain is observed while moving or turning the ankle.
5. Joint Swelling and Tenderness- Ankle joint is swollen and tender. Swelling is because of tissue inflammation and blood clot (hematoma) that spreads in subcutaneous tissue.
6. Ambulation Difficulty- Individual is unable to put weight on ankle and unable to walk with cane and walker. Most of the ambulation is depending on use of wheel chair.

Diagnosis of medial malleolus fracture can be made based on the history, clinical examination and reading the images following radiological studies.

1. History of Injury and Symptoms- The history often reveals an accident, fall or sports injury, while stress fracture can be suspected in long term slowly increasing pain.
2. Examination- Examination confirms the pain, tenderness and swelling. The findings are evaluated to understand if it is a soft tissue injury or a fracture. Examination confirms if fracture is compound fracture or closed fracture.
3. Investigations- Investigations mostly performed to diagnosed fracture and soft tissue injuries are radiological studies and ultrasound examination of ankle joint.

1. Radiological Studies⁵–

   • X-Ray– X-ray confirms a break in the bone and also gives an idea about the type and severity of medial malleolus fracture. X-Ray distinguishes fracture type like stress, non-displace, displace and comminuted fracture.
   • CT Scan– Images of Computerize Tomography (CT) scan shows fracture as well as soft tissue injuries like fracture of tendon, bleeding and muscle tear. CT scan shows 3 dimensional view and better images of type of fracture
   • MRI– Magnetic Resonance Imaging shows images similar to CT scan.

2. Ultrasound Examination- Ultrasound examination shows images of blood clot, tendon and muscle injury.

3. Blood Examination- White blood cell count is elevated if there is infection around the fracture area.

Treatment of medial malleolus fracture includes conservative (non-surgical) treatment, medications and surgical treatment. Treatment selection depends on the type and severity of the medial malleolus fracture and the condition of the patient.

1. Conservative Treatment of Medial Malleolus Fracture

   1. Heat Therapy
   2. Cold Therapy
   3. Rest and Leg Elevation
   4. Braces
   5. Cast

2. Medications

   1. NSAIDs
   2. Tylenol
   3. Opioids
   4. Antibiotics

3. Physical Therapy

4. Surgery for Treating Medial Malleolus Fracture

1. External Fixation

• Insertion of wires
• External screws and fragment stabilization

2. Internal Fixation

1. Insertion of wires
2. Placement of screws and rods or plates

3. Open Reduction

5. Interventional Therapy

6. Rehabilitation Therapy

1. Conservative Treatment-

   Conservative treatment is recommended until radiological studies completed. Conservative treatment also beneficial to treat hairline fracture. Usually, conservative treatment of medial malleolus fracture, is recommended for less severe and uncomplicated injuries. Unstable fracture with fragment of fractured bone not out of place can be managed well with conservative or non-surgical treatment. Conservative treatment may also be advised when the fractured pieces of bones are too small to be repaired surgically. Usually, weight bearing on the fractured leg is to be avoided for at least 6 weeks, post which, it depends on the healing of the fracture. Regular monitoring and repeated X-rays may be taken to check the healing and to detect any change of position of the fracture.

1. Heat Therapy- Heat dilates blood vessels and may cause increased bleeding. In most cases of fracture of medial malleolus heat therapy is avoided during initial phase. Heat helps to reduced pain during healing phase of injury after surgery and 5 to 7 days following injury.
2. Cold Therapy- Icing can be done for pain and swelling. Icing is most effective during initial phase to prevent swelling of injured soft tissue. Icing also reduces bleeding and loss of blood. In most cases immediate application of ice helps to reduce hematoma and bruises.
3. Rest and Leg Elevation- Patient is advised to take a rest and keep leg elevated if injury has caused hairline fracture or nondisplaced fracture of medial malleolus.
4. Braces- Hairline fracture is treated with pain medication and braces.
5. Cast- Hairline and non-displaced fracture in active patient is treated with placing cast over the ankle.

2. Medications to Treat Medial Malleolus Fracture-

   1. Non-steroidal Anti-inflammatory medications- Treatment of medial malleolus fracture also includes the use of non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs helps to reduce inflammation and swelling of the joint. NSAIDs also decreases secretion of prostaglandin enzyme that helps to reduce the pain.
   2. Tylenol- Mild to moderate pain is treated with tylenol. Tylenol is also used instead if NSAIDs if patient develops stomach pain after taking NSAIDs.
   3. Opioids- Severe pain that is not responding to NSAIDs and Tylenol is treated with opioids. Opioid therapy is restricted for 2 to 3 weeks since recent study suggests opioid causes addiction and dependence.
   4. Antibiotics- Infection is rare in cases of closed medial malleolus fracture. Infection is observed following surgery and in patient sustained compound fracture. Infection is then treated with antibiotics. Choice of antibiotics depends on type of bacterial infection.

3. Physical Therapy-

   Physical therapy for medial malleolus fracture is recommended after healing of wound. Physical therapy helps to rehabilitate. Physical therapy helps to regain strength of muscle and also improve joint mobility.

4. Surgery-

   Type of surgery recommended depends on the severity of injury and complications. Choices of surgical treatment depends on type of injury. and bone fragments, most surgical corrections are done using screws, plates and wiring options. Possible complications of surgery of medial malleolus fracture include the risk of infections and delayed healing.

   

1. External Fixation

   1. Insertion of Wires- External fixation is performed under local anesthesia and sedation. X-Ray or CT scan is used to target the fractured fragments. The wire is passed through skin into the fractured fragments. The fragments are pulled to align as much as close to anatomical position. The wire is then tightened to hold fractured fragments together. Periodic X-ray is done to make sure fragments are not separated. Healing depends on close proximity of fractured fragments.
   2. External Screws and Fragment Stabilization- The surgery is performed under sedation and local anesthesia. Instead wired screws are inserted in fractured fragments. The external end of screws are connected to external rod that pulls fractured fragment close until fragment ends are close and more in normal anatomical position.

2. Internal Fixation

   1. Insertion of Wires- Internal fixation involves small skin incision, Procedure is performed under sedation or anesthesia. X-ray is used to identify fracture fragments. The wire is passed through fragments, the fragments are then brought close by tightening wire. Once the acceptable reduction of fracture is observed in X-Ray then wire is buried under subcutaneous tissue and skin is closed with sutures.
   2. Placement of Screws and Rods or Plates⁴– Surgical procedure is performed under anesthesia. X-ray is used during surgery. Bone fragments are aligned together and position is maintained by passing screws through fragments and other end of screw connected to rod or plate. Once the position is accepted then skin wound is closed.

3. Open Reduction Surgery to Treat Medial Malleolus Fracture

   Open reduction surgery is performed under spinal anesthesia or general anesthesia. The adequate incision is taken so all the fracture fragments are seen. The fragments are manually brought together and aligned in anatomical position. The wire or screw is passed between two fractured bones. The other end of screw is anchored to rod or plate. Once the fractured fragments are fixed and does not move then the skin is closed.

1. Interventional Therapy- Interventional therapy for medial malleolus fracture is recommended for chronic pain that continues after wound is healed. Conservative therapy includes injection of cortisone close to the fracture site.

2. Rehabilitation- Rehabilitation is a necessary part of treatment of medial malleolus fracture. Whether the fracture is treated with conservative or surgical treatment, the appropriate rehabilitation programs promotes better healing. Rehabilitation reduces the risk of long term pain and complications. Rehabilitation treatment includes physical therapy, training to do desk job and proper ambulation technique as well as training to use walker and wheelchair until injured person is capable of walking without any help.

In case of fresh injury to the ankle joint, which results in a possible medial malleolus fracture, emergency treatment is needed.

• Hairline Fracture- Hairline fracture of medial malleolus does not need surgery and mostly treated with braces and pain medications.
• Stable Non-Displaced Fracture- Such fracture is also initially treated with conservative treatment and cast.
• Displaced Unstable Fracture- Displaced unstable fracture shows unstable fractured segment and substantial gap between the fragment possibly caused by tissue lying between the fragment. Such fracture demands approximation of fractured fragments for proper alignment and healing.
• Medial Malleolus Fracture And Torn Achilles Tendon- Such injury needs surgery to correct fracture as well as repair tear of Achilles tendon. x Such multiple injuries need immediate medical assistance.
• Compound Fracture- The severe injury following work or car accident causes split in skin and soft tissue that protects the joint and bone. Such injury exposes bones to atmosphere and may get infected. Compound fracture needs extensive surgery to repair skin, subcutaneous tissue, muscle tendon and fracture bones.

1. Mal-aligned Fractured Fragments
2. Failed Conservative Treatment
3. Compound Fracture
4. Risk of non-union

1. Mal-Aligned Fracture Fragments- Generally surgical treatment of medial malleolus fracture is recommended when the fracture is out of place or mal-aligned.
2. Failed Conservative Treatment- Surgical treatment for medial malleolus fracture is also considered following failed conservative treatment when fractured fragments of bone remain not aligned and not fused.
3. Compound Fracture- Compound medial malleolus fracture is treated with open surgery.
4. Risk of Non-Union- Sometimes, even if the fracture is not out of place, but if there seems a risk of non-union or if the patients are very active, surgery may be considered. Surgery is often performed to align and stabilize the bones.

Recovery time for medial malleolus fracture to heal depends on the type of fracture. Hairline fracture heals in 6 to 8 weeks. Compound fracture following open surgery may take long period of time heal. The expected time to heal is between 12 to 16 weeks. In few case recovery time may prolong if injured person is suffering with wound infection or osteoporosis. Such cases may take to 16 to 24 weeks. However, in some cases, few injured individuals may suffer with chronic pain. The recovery time to get completely better from chronic pain may take several months.

References:  

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