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ankle injuries and fractures

patient information sheets


general key points

  • consider the mechanism of injury
    • fall from a height suggests possible fractures of:
      • tibial plafond (pilon fracture)
      • talar neck fracture if in crouching position during fall
      • calcaneal fracture
      • Lisfrance fracture/dislocation tarso-metatarsal joints
      • thoraco-lumbar spine fracture
    • inversion injuries often fracture the base of 5th MT, or may cause a Jones fracture (location at the metadiaphyseal junction at proximal fifth metatarsal), thus if tender, Xray foot
    • palpate for tenderness over the proximal fibula to exclude potential Maisonneuve fracture (proximal fibular fracture associated with medial-sided and syndesmotic injury)
  • examine closely to exclude possibility of open fracture (ie. breach of skin) which needs early orthopaedic Mx.
  • osteochondral fractures of the talar dome are easily missed on routine Xrays, therefore, persistent ankle pain may require additional imaging studies


  • lateral ankle sprains account for ~90% of adult ankle injuries
  • ankle fractures occur in ~15% of those who present to doctors
  • most unstable ankle fractures in adults are the result of excessive external rotation of the talus with respect to the tibia:
    • if the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues
    • if the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results
  • displaced fracture/dislocations of the ankle MUST be reduced ASAP within minutes to reduce risk of skin breakdown
  • adults placed in back slab or cast, or a moon boot should have a formal VTE assessment, and if at high risk, should be considered for VTE prophylaxis with enoxaparin
    • currently, most orthopaedic surgeons advise that those without high risk are generally NOT given anticoagulation as risks outweigh benefits
    • recent research shows that risk of fatal PE in all patients with these injuries requiring immobilization is extremely low - perhaps 1 in 5000, but giving anticoagulants does double rates of adverse effects although also decreases symptomatic DVTs (need to treat 14 patients to have 1 less symptomatic DVT). There is as yet no reliable evidence to prove that anticoagulation reduced fatal PEs in this group.
  • all adults immobilized as above should be given a VTE patient advice sheet:


  • in children, tenderness over the lateral malleolus suggest a type I Salter-Harris classification of epiphysial plate injury, even if radiographic findings are negative, although fortunately, most can be managed as for a severe sprain.
  • SHII fractures of the distal tibia are common and best seen on the lateral view as the distal tibia epiphysis displacing anterior to the tibial shaft - these usually require early (< 1 week) closed reduction.
  • a Tillaux fracture is a SHIII fracture involving the anterolateral tibial epiphysis that is commonly seen in adolescents and may require early ORIF if remains displaced > 2mm.
  • a longitudinal lucency at the base of the 5th metatarsal is the growth plate of the apophysis and NOT a fracture.
  • a transverse lucency at the base of the 5th metatarsal suggests a fracture NOT a growth plate.
  • children also not uncommonly have fractures across the necks or the bases of the 2nd-4th MT's - have a lower threshold for Xray of painful feet after a fall.
  • young children often present with a limp after a minor fall and there are no obvious areas of tenderness - these children should have a tibia and fibula Xray to exclude a toddler fracture of shaft of tibia.

is an Xray really needed?

  • only ~15% of patients presenting with ankle injuries will have a fracture on Xray
  • for the remainder, although there is some psychological reassurance from doing an Xray, it adds cost, time, contributes to ED overcrowding, and adds more radiation exposure unnecessarily.
  • use of the Ottawa ankle rules to decide on who should have an Xray, can reduce the number of adult ankle Xrays required to ~35% of patients presenting, whilst still picking up nearly all significant fractures.
  • the main barrier to their use is patient acceptance and physician awareness and preparedness to use them.

Ottawa ankle rules

  • see also Wikipedia
  • DO NOT USE these rules if either patient is:
    • pregnant
    • has diminished ability to follow the test (for example due to head injury or intoxication)
    • child (under the age of 18) - although some evidence to support use in this age group, but not the foot rules
  • X-rays are only required if there is bony pain in the malleolar zone and any one of the following:
    • bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
    • bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
    • an inability to bear weight both immediately and in the emergency department for four steps.
  • in addition, foot Xray is required according to the Ottawa Foot Rules if either:
    • there is bony pain in the midfoot zone, and any one of the following:
      • bone tenderness at the base of the fifth metatarsal
      • bone tenderness at the navicular bone
      • an inability to bear weight both immediately and in the emergency department for four steps

Mx of the sprained ankle

  • patients with severe sprains as evidenced by substantial swelling and/or bruising appear to gain earlier mobility if placed in a below knee plaster cast or backslab for the first 10 days1), followed by physiotherapy.
    • the early immobilised group had better results at 3 months but equal results at 12 months
  • other patients are usually managed by a period of RICE - Rest, Ice, Compression with tubigrip bandage, and Elevation followed by physiotherapy.
  • The goal of rehabilitation should be symmetric range of motion and 85% of contralateral strength prior to returning to sport.

nomenclature for ankle fractures

  • ankle fractures can be classified as single malleolar, bimalleolar, and trimalleolar if the posterior part of the tibial plafond is involved.
    • bimalleolar or trimalleolar injuries are always unstable and are treated with open reduction and internal fixation (ORIF).
  • barely visible osseous chip fractures do not alter the routine active management of grade 1 and 2 ankle sprains.
  • careful attention must be paid to all single malleolar fractures because ligament instability is frequently associated with the contralateral side.
    • in the presence of medial malleolar tenderness and more than 5 mm of medial clear space on the mortise view, make a presumptive diagnosis of deltoid ligament rupture if a displaced fibular fracture is present. Treat these injuries as unstable bimalleolar fracture warranting orthopaedic opinion +/- ORIF.
  • distal fibula fractures are the most common fracture type to the ankle, and the Danis-Weber classification system is listed below.

simple Danis-Weber classification of lateral malleolar fractures

Weber A

  • transverse fracture of fibula BELOW the level of the ankle joint
  • stable and can be managed by closed reduction if needed
  • may require ORIF if associated with a displaced medial malleolar fracture

Weber B

  • spiral fracture of fibula AT the level of the ankle joint
  • occurs secondary to external rotational forces
  • may require ORIF depending on ligamentous injury or associated fractures on the medial side

Weber C

  • fracture ABOVE the level of the ankle joint
  • disrupts the ligamentous attachment between the fibula and the tibia distal to the fracture
  • unstable - needs ORIF
trauma_ankle.txt · Last modified: 2019/04/07 22:49 by

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