A broken ankle is also known as an ankle “fracture.” This means that one or more of the bones that make up the ankle joint are broken.

A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces your ankle out of place and may require that you not put weight on it for a few months.

Anatomy

Three bones make up the ankle joint:

• Tibia – shinbone
• Fibula – smaller bone of the lower leg
• Talus – a small bone that sits between the heel bone (calcaneus) and the tibia and fibula

The tibia and fibula have specific parts that make up the ankle:

• Medial malleolus – inside part of the tibia
• Posterior malleolus – back part of the tibia
• Lateral malleolus – end of the fibula

Reproduced and adapted with permission from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

Doctors classify ankle fractures according to the area of bone that is broken. For example, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both the tibia and fibula are broken, it is called a bimalleolar fracture.

Two joints are involved in ankle fractures:

• Ankle joint – where the tibia, fibula, and talus meet
• Syndesmosis joint – the joint between the tibia and fibula, which is held together by ligaments

Cause

• Twisting or rotating your ankle
• Rolling your ankle
• Tripping or falling
• Impact during a car accident

Symptoms

Because a severe ankle sprain can feel the same as a broken ankle, every ankle injury should be evaluated by a physician.

Common symptoms for a broken ankle include:

• Immediate and severe pain
• Swelling
• Bruising
• Tender to touch
• Cannot put any weight on the injured foot
• Deformity (“out of place”), particularly if the ankle joint is dislocated as well

Evaluation

Imaging Tests

X-rays. X-rays are the most common and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there is displacement (the gap between broken bones). They can also show how many pieces of broken bone there are. X-rays may be taken of the leg, ankle, and foot to make sure nothing else is injured.

Computed tomography (CT) scan. This type of scan can create a cross-section image of the ankle and is sometimes done to further evaluate the ankle injury. It is especially useful when the fracture extends into the ankle joint.

Magnetic resonance imaging (MRI) scan. These tests provide high resolution images of both bones and soft tissues, like ligaments. For some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.

Treatment: Lateral Malleolus Fracture (fibula fracture)

A lateral malleolus fracture is a fracture of the fibula.

There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.

Different levels of lateral malleolus fractures

Reproduced with permission from Michelson JD: Ankle Fractures Resulting From Rotational Injuries J Am Acad Ortho Surg 2003;11:403-412.

Nonsurgical Treatment

You may not require surgery if your ankle is stable, meaning the broken bone is not out of place or just barely out of place. If it is determined that surgery is not required, immobilization with either a cast or a walking boot is utilized. Typically, no weight is allowed on the foot for 6 weeks to allow the bone to heal.

Surgical Treatment

If the fracture is out of place or your ankle is unstable, your fracture will be treated with surgery. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with screws and metal plates attached to the outer surface of the bone.

Treatment: Medial Malleolus Fracture (tibial fracture)

A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures can occur at different levels of the medial malleolus.

Medial malleolar fractures often occur with a fracture of the fibula (lateral malleolus), a fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle ligaments.

Nonsurgical Treatment

If the fracture is not out of place or is a very low fracture with very small pieces, it can be treated without surgery.

A stress x-ray may be done to see if the fracture and ankle are stable.

The fracture may be treated with a short leg cast or a removable brace. Usually, you need to avoid putting weight on your leg for approximately 6 weeks.

Surgical Treatment

If the fracture is out of place or the ankle is unstable, surgery may be recommended.

In some cases, surgery may be considered even if the fracture is not out of place. This is done to reduce the risk of the fracture not healing (called a nonunion), and to allow you to start moving the ankle earlier.

the bone fragments are fixed using screws, a plate and screws, or different wiring techniques.

Treatment: Posterior Malleolus Fracture

A posterior malleolus fracture is a fracture of the back of the tibia at the level of the ankle joint.

In most cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken. This is because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.

Depending on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and should be treated with surgery.

Nonsurgical Treatment

If the fracture is not out place and the ankle is stable, it can be treated without surgery.

Treatment may be with a short leg cast or a removable brace. Patients are typically advised not to put any weight on the ankle for 6 weeks.

Surgical Treatment

If the fracture is out of place or if the ankle is unstable, surgery may be offered.

Different surgical options are available for treating posterior malleolar fractures. One option is to have screws placed from the front of the ankle to the back, or vice versa. Another option is to have a plate and screws placed along the back of the shin bone.

Treatment: Bimalleolar Fractures or Bimalleolar Equivalent Fractures

“Bi” means two. “Bimalleolar” means that two of the three parts or malleoli of the ankle are broken. (Malleoli is plural for malleolus.)

In most cases of bimalleolar fracture, the lateral malleolus and the medial malleolus are broken and the ankle is not stable.

A “bimalleolar equivalent” fracture means that in addition to one of the malleoli being fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.

A stress test x-ray may be done to see whether the medial ligaments are injured.

Bimalleolar fractures or bimalleolar equivalent fractures are unstable fractures and can be associated with a dislocation.

Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

Nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk. Weightbearing is not be allowed for 6 weeks. After 6 weeks, the ankle may be protected by a removable brace as it continues to heal.

Surgical Treatment

Surgical treatment is often recommended because these fractures make the ankle unstable.

Lateral and medial malleolus fractures are treated with the same surgical techniques as written above for each fracture listed.

(Left) X-ray of bimalleolar ankle fracture. (Right)Surgical repair bimalleolar ankle fracture.

Treatment: Trimalleolar Fractures

“Tri” means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.

Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

As with bimalleolar ankle fractures, nonsurgical treatment might be considered if you have significant health problems, where the risk of surgery may be too great, or if you usually do not walk.

Surgical Treatment

Each fracture can be treated with the same surgical techniques as written above for each individual fracture.

(Left) X-ray of trimalleolar ankle fracture. (Right) Surgical repair.

Treatment: Syndesmotic Injury

The syndesmosis joint is located between the tibia and fibula, and is held together by ligaments. A syndesmotic injury may be just to the ligament — this is also known as high ankle sprain. Depending on how unstable the ankle is, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.

In many cases, a syndesmotic injury includes both a ligament sprain and one or more fractures. These are unstable injuries and they do very poorly without surgical treatment.

(Left) X-ray of syndesmotic injury with lateral malleolus fracture. Note the space between the tibia and fibula. (Right) Surgical repair.

Recovery

Because there is such a wide range of injuries, there is also a wide range of how people heal after their injury. It takes at least 6 weeks for the broken bones to heal. It may take longer for the involved ligaments and tendons to heal.

Rehabilitation

Rehabilitation is very important regardless of how an ankle fracture is treated. Doing your exercises regularly is key. It may take several months for the muscles around your ankle to get strong enough for you to walk without a limp and to return to your regular activities.

Weightbearing

Your specific fracture determines when you can start putting weight on your ankle. It is very important to not put weight on your ankle until told to do so. If you put weight on the injured ankle too early, the fracture fragments may move or your surgery may fail resulting in complications.

Complications

People who smoke, have diabetes, or are elderly are at a higher risk for complications after surgery, including problems with wound healing. This is because it may take longer for their bones to heal.

Surgical Treatment

General surgical risks include:

• Infection
• Bleeding
• Pain
• Blood clots in your leg
• Damage to blood vessels, tendons, or nerves

Risks from the surgical treatment of ankle fractures include

• Difficulty with bone healing
• Arthritis
• Pain from the plates and screws that are used to fix fracture. Some patients choose to have them removed several months after their fracture heals

Outcomes

Although most people return to normal daily activities, except for sports, within 3 to 4 months, studies have shown that people can still be recovering up to 2 years after their ankle fractures. It may take several months for you to stop limping while you walk, and before you can return to sports at your previous competitive level.

The Achilles tendon is a strong, rope-like structure located in the back of the leg that links the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). This muscle/tendon unit produces the majority of the force required to put the foot down during walking or running.

Injuries to the Achilles tendon vary from mild (tendonitis), a partial rupture, or complete rupture.

When the Achilles tendon tears, patients often report a tearing or popping sensation behind the ankle. Symptoms include tenderness, swelling, and/or bruising around the ankle. If there is a complete rupture, a palpable defect may be present.

Treatment for an Achilles tendon tear depends on many factors including age, activity level, and vocation. In certain patients, conservative non-operative treatments may be indicated. Larger tears and those affecting younger, more active patients may require surgical repair.

When surgery is indicated, Dr. Dedhia utilizes an open repair technique. He begins by making an incision in the skin just above the heel bone. The torn ends of the Achilles tendon are then freed from surrounding scar tissue. Once free, sutures (stiches) are weaved in an organized fashion through each end of the torn tendon. The foot is then plantar flexed (heel raised with toes pointing down) to minimize tension on the repair. The two ends are brought together and one suture string from each end are tied together. Once all the sutures have been tied and the Achilles tendon is appropriately reduced, the skin incision is closed.

You will be placed in a splint or cast that starts just below the knee down to your toes. The foot will remain in a plantar flexed position to reduce tension on the repair.

The decision to have an Achilles tendon tear surgically repaired is based on numerous factors and can be discussed in detail during your office visit with Dr. Dedhia.