Overview of ankle fractures in adults

Authors: Scott M Koehler, MD, Patrice Eiff, MD

Section Editor: Chad A Asplund, MD, MPH, FAMSSM
Deputy Editor: Jonathan Grayzel, MD, FAAEM

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Jan 2021. | This topic last updated: Oct 31, 2019.

INTRODUCTION

Ankle fractures are increasingly common injuries that necessitate a careful

approach for proper management. Over five million ankle injuries occur each year
in the United States alone [1].

This topic review will provide an overview of ankle fractures that result from minor
trauma (ie, indirect or low energy fractures), including a basic approach to their
evaluation and management. Fibular fractures above the lateral malleolus, tibial
fractures, and ankle injuries other than fractures are discussed elsewhere. (See
"Fibula fractures" and "Overview of tibial fractures in adults" and "Ankle sprain" and
"Non-Achilles ankle tendinopathy".)

EPIDEMIOLOGY AND RISK FACTORS

The incidence of ankle fractures is approximately 187 fractures per 100,000

people each year [1]. Since the mid-1900s, this rate has increased significantly in
many industrialized countries, most likely due to growth in the number of people
involved in athletics and in the size of the elderly population [1-3].
The vast majority of ankle fractures are malleolar fractures: 60 to 70 percent occur
as unimalleolar fractures, 15 to 20 percent as bimalleolar fractures, and 7 to 12
percent as trimalleolar fractures [1,4]. There are similar fracture rates overall
between women and men, but men have a higher rate as young adults, while
women have higher rates in the 50 to 70-year age group [1,4].

Cigarette smoking and a high body mass index have been associated with ankle
fractures [5,6]. In contrast to fractures of the radius and other fractures common
among perimenopausal and postmenopausal women, bone density has not been
clearly demonstrated to be a major risk factor [7].

CLINICAL ANATOMY

The bony anatomy of the ankle consists of the articulation of the distal tibia and
fibula with the talus (figure 1 and figure 2 and figure 3). These bones are held
together by the ligaments of the ankle to form a mortise. The weight-bearing
portion of the mortise consists of the tibial plafond and the talar dome. The
mortise gains its stability from the bony relationships of the ankle and from
surrounding structures.

The lateral ligament complex consists of the anterior talofibular ligament, the
calcaneofibular ligament, and the posterior talofibular ligament (figure 4). The
medial ankle complex consists of the deep and superficial fibers of the deltoid
ligament (figure 5). The peroneal tendons, anterior and posterior tibialis tendons,
Achilles tendon, and joint capsule provide additional support (figure 6).

The syndesmosis of the ankle refers to the articulation of the distal tibia and
fibula. Support is provided by the anterior tibiofibular ligament, the posterior
tibiofibular ligament, the transverse tibiofibular ligament (posteriorly), and the
interosseous membrane, which extends from the ankle proximally. These
structures prevent the distal tibia and fibula from separating. Abnormal forces that
rotate the talus within the mortise push the tibia and fibula apart and may cause
an injury to the syndesmotic ligaments or a fracture.

The motion of the ankle is complex. Although the joint moves primarily in the
sagittal plane to enable dorsiflexion and plantarflexion of the foot, motion occurs
in several planes. Inversion and eversion of the foot occur mainly at the subtalar
joint.

The talar dome is narrower posteriorly. It therefore fits more tightly into the
mortise, creating greater joint stability, when the ankle is dorsiflexed [3,8]. The
position of the talus in the mortise depends more on the medial supporting
structures, which are stronger, than the lateral structures. Therefore, the ankle is
better able to withstand forces that stress the medial side of the joint [9].

The posterior tibial artery and tibial nerve run together just posterior and lateral to
the medial malleolus. The anterior tibial artery (dorsalis pedis in the foot) and
deep peroneal nerve run together and cross the ankle joint anteriorly,
approximately in the midline, just lateral to the extensor hallucis longus and below
the extensor retinaculum.

There is no single, widely accepted definition of the anatomic margins of the

lateral malleolus. For the purpose of this review, the lateral malleolus refers to the
distal part of the fibula that articulates with the talus and distal tibia. Lateral
malleolar fractures are those that lie between the distal tip of the fibula and the
most proximal portion of the fibula that lies directly adjacent to the tibia in the
tibial groove (image 1).

The lateral malleolus provides stability against excessive eversion of the ankle and
foot. The medial malleolus is the most distal part of the tibia and articulates with
the medial aspect of the talar dome. The posterior aspect of the distal tibia is
commonly referred to as the posterior malleolus. It primarily includes the portion
of the tibia where the syndesmotic ligament complex attaches.
MECHANISM OF INJURY

Overview — Ankle injuries that result from bending forces are commonly

described as inversion or eversion injuries. Technically, inversion and eversion are
motions of the subtalar joint and become supination and pronation when
combined with ankle and midfoot motion. Internal and external rotation of the
ankle refers to the rotation of the talus within the joint.

Supination (inversion) injuries typically cause distraction of the lateral ankle

structures and compression of the medial structures. Pronation (eversion) injuries
cause medial distraction and lateral compression. Structures being distracted (or
stretched) generally fracture or tear before structures being compressed. As an
example, injuries that occur while the ankle is supinated will result in damage to
the distal fibula and its associated ligaments, which are being stretched, before
any damage occurs to the distal tibia and its deltoid ligament complex.

In addition to bending forces, rotational forces often contribute to ankle injuries by

placing further stress on supporting structures and forcing the malleoli apart.

Historically, orthopedists have classified the mechanism of injury using two

descriptors. The first describes the position of the ankle at the time of injury; the
second refers to the force applied to the ankle that causes the injury. As an
example, a "supination/external rotation" injury refers to the ankle in a supinated
position with an external rotation force applied to it. These descriptors predict the
sequence in which structures are injured and provide the basis for the Lauge-
Hansen system of ankle fracture classification used to guide orthopedic decision
making. The amount of force sustained during the injury is a third factor, in
addition to ankle position and force direction, which determines the type and
extent of injury.

Several studies question the accuracy of the Lauge-Hansen scheme [10,11]. A

complete discussion of classification systems is beyond the scope of this review
and can be found elsewhere [3,9,12].

One classification scheme deserves further mention because of its simplicity and
clinical relevance. In this approach, the ankle is conceived as a ring of supporting
structures surrounding the talus (figure 7) [8]. Supporting structures may be
ligaments or bones. If the ring is broken at one site, the injury is stable and can be
managed nonoperatively; if the ring is broken at two or more sites, the injury is
unstable and is managed operatively.

Malleolar fractures — Isolated malleolar fractures tend to be stable if they are

nondisplaced (ie, there is no contralateral or syndesmotic injury). However, care
must be taken with fractures of the medial malleolus. Disruption of lateral or
posterior structures often occurs in association with these fractures, though they
may initially appear to be isolated injuries.

Posterior malleolar fractures occur either from the impact of the talus on the
posterior aspect of the tibia (often as part of a pilon fracture (image 2)) or from an
external rotation or pronation (eversion) force. They occur in association with
disruption of the posterior tibiofibular ligament. Posterior malleolar fractures rarely
occur in isolation [13]. They are more commonly associated with fibular fractures
and additional ligament damage, and they are generally unstable injuries.

Fractures of both the lateral and medial malleoli are called bimalleolar and are
generally unstable. A bimalleolar fracture with a fracture of the posterior malleolus
is referred to as a trimalleolar fracture. Trimalleolar fractures are unstable and
typically occur with injuries of greater force. They have a higher risk of
complication than bimalleolar fractures and require surgical stabilization.

CLINICAL PRESENTATION AND EXAMINATION

Emergency conditions, such as an open fracture, neurovascular compromise, or

fracture dislocation, must be treated immediately. (See 'Initial treatment' below.)
In addition to the mechanism of injury, the clinician’s history should ascertain the
following:

● Site of the most significant pain

● Other injured areas (eg, lumbar spine, hip, knee)
● Length of time from injury to presentation
● Neurovascular symptoms
● Ability to bear weight
● History of any previous injury or surgery
● Related comorbidities (eg, diabetes)

An ankle fracture, particularly one sustained in a fall, may mask other injuries such
as a lumbar compression fracture.

Clinicians should inspect the injured ankle for:

● Swelling
● Deformity
● Skin abnormalities, such as lacerations (possible open fracture), tenting, or
blistering (caused by rapid stretching of the skin)

The amount of swelling is not a reliable guide to the presence of a fracture.

Clinicians should palpate the ankle looking for the point of maximal tenderness
and other tender areas. The examiner should palpate the tibia and fibula,
especially the fibular neck, to evaluate for possible associated fractures. Testing
for ligamentous laxity can be deferred until after radiographs are obtained; it is
often not tolerated in the setting of an acute fracture.

Pulses of the dorsalis pedis and posterior tibialis arteries and distal capillary refill
should be checked. Sensation and motor function should be assessed. A detailed
discussion of the physical examination of the ankle is found elsewhere. (See
"Ankle sprain".)
Once emergency conditions have been ruled out, the first priority in the evaluation
of ankle fractures is to determine whether the fracture is stable, and can be
managed nonoperatively, or unstable, and must be referred. Typically, an ankle
fracture is stable if it meets the following criteria:

● It is isolated to the lateral, medial, or posterior malleolus.

● It is nondisplaced.
● It is not associated with a ligamentous injury.

An ankle fracture is unstable if two or more sites of significant injury are present,
such as a lateral malleolar fracture with deltoid ligament disruption or a
bimalleolar fracture. (See 'Indications for orthopedic consultation or referral'
below.)

RADIOGRAPHIC FINDINGS

The Ottawa ankle rules have been shown to help the examiner in determining if
radiographs of the ankle or foot are needed in the evaluation of an acute ankle
injury (figure 8).

Patients who do not meet the Ottawa criteria are unlikely to have a fracture, and
radiographs are typically not needed in the acute setting [14]. A full discussion of
the Ottawa rules is found elsewhere. (See "Ankle sprain", section on 'Ottawa ankle
rules'.)

Ankle fractures are typically evaluated using plain radiographs. Anterior-posterior

(AP), oblique, and lateral views are standard. The oblique radiograph, also called
the mortise view, should be obtained as an AP projection with a 10 to 20 degree
lateral angle to help visualize injuries of the syndesmosis and talus (image 3). On
the mortise view, the relationship of the medial and lateral malleoli can be
measured with respect to the talus. Normally, the distances between the talus and
the lateral malleolus, the talus and the medial malleolus, and the talus and the
tibial plafond are uniform throughout the mortise.

Isolated lateral and medial malleolar fractures are best seen on the AP view (
image 4 and image 5). Posterior malleolar fractures are best seen on the lateral
view (figure 9 and image 6). On the mortise view, discrepancies in the relationship
between the talus and the medial and lateral malleoli can help identify an unstable
fracture or soft tissue injury (image 7 and image 8).

The presence of medial injury determines the stability of lateral malleolar

fractures. Stress radiographs are needed to determine the stability of the joint in
cases of a lateral malleolar fracture with deltoid ligament tenderness but no
widening of the joint on initial radiographs. Deltoid ligament injury is assumed if a
distance greater than 4 mm is measured between the talus and the medial
malleolus on either a standard mortise or stress radiograph (image 8) [12,15].
Adequate external rotation of the foot is necessary for obtaining accurate stress
radiographs. Clinicians should avoid inflicting undue pain when obtaining such
studies by providing adequate analgesia and limiting the force applied when this
causes excessive discomfort.

The gravity stress mortise radiograph has been shown to be as sensitive and
specific as a manual stress mortise radiograph (picture 1) [15,16]. A decision
about surgical intervention should not be based on stress radiographs alone. The
integrity of the deltoid ligament can be further assessed with magnetic resonance
imaging (MRI) or ultrasound [17] if necessary.

Isolated medial malleolar and isolated posterior malleolar fractures are

considered stable if no associated injury or tibiotalar joint displacement is present,
fracture displacement is equal to 2 mm or less, and joint surface involvement is
less than 25 percent [9,12,13]. In the case of isolated posterior malleolar fractures,
no displacement on a lateral radiograph is acceptable. If it is unclear whether
displacement is present on plain radiograph, a CT scan should be obtained [18].
If a fracture of the talus is suspected, or if significant comminution is present, a CT
scan will further delineate the extent of the injury and identify fracture
displacement. If plain films are negative and clinical suspicion is high for specific
soft tissue or cartilage injuries, MRI is more useful (image 9 and figure 3). Both
MRI and triple-phase bone scintigraphy (bone scan) (image 10) are helpful in
diagnosing a stress fracture in the ankle region, especially if plain radiographs are
normal. (See "Overview of stress fractures".)

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL

Open fractures and any injury with associated neurologic or vascular deficits
require immediate surgical referral.

The two major indications for operative fixation of an ankle fracture are loss of
joint congruency or loss of joint stability [3,9,12]. Loss of joint congruency, such as
occurs with severe posterior malleolar fractures and pilon fractures, occurs in the
setting of more severe trauma (pilon fractures occur when relatively strong axial
forces drive the tibial plafond into the talar dome (image 2)). Fractures that create
joint instability as a result of minor trauma are more common.

Typically, an ankle fracture is unstable if two sites of significant injury are present.
All trimalleolar, bimalleolar, and isolated malleolar fractures with an opposing
ligament rupture (eg, a lateral malleolar fracture with deltoid ligament disruption)
are unstable and require orthopedic referral. If there is any uncertainty about the
stability of the ankle, the patient should be referred. Unstable fractures are
generally managed surgically although, in some instances at centers with
appropriate expertise, may be treated with molded casting [19].

Injuries that lead to a distal fibular fracture above the tibiotalar joint line are almost
always associated with a syndesmotic disruption and should be referred to an
orthopedist (image 11 and image 12 and image 13). Posterior malleolar fractures
that result in loss of joint congruency should also be referred.
Unstable fractures often require open reduction with internal fixation. Whether
operative or nonoperative management is used, the goal of treatment is anatomic
alignment to maximize function and minimize the risk of post-traumatic
osteoarthritis.

TREATMENT

Initial treatment — Emergency conditions, such as an open fracture or

neurovascular impairment, require immediate surgical consultation and treatment.
Fracture dislocations must be reduced immediately to prevent severe
complications, such as avascular necrosis.

Once emergency conditions are excluded, clinicians should evaluate the fracture
more closely, focusing on any malalignment or instability, to determine proper
management and follow-up (see 'Indications for orthopedic consultation or
referral' above). The ankle should be splinted at 90 degrees (ie, neutral position) to
provide support and control pain. Usually, a short-leg posterior splint is sufficient.
A sugar-tong (ie, coaptation) splint can be added for additional mediolateral
support. If significant swelling or deformity is present, adequate padding should
be placed prior to application of the splint to allow for further swelling, while
maintaining stability.

Clinicians should instruct the patient to call immediately for:

● Pain that is severe or increasing

● Numbness that is new or worsening
● Skin discoloration (eg, dusky toes) distal to the splint

These complaints may represent vascular compromise or some other serious

complication and should be investigated immediately. Any patient complaint of
skin irritation, a splint which has become excessively tight or loose, or a splint
which has gotten wet should also be assessed. An examination and repeat
radiographs to check for acceptable alignment are generally performed during the
first follow-up visit at 7 to 10 days.

For stable, nondisplaced, isolated malleolar fractures, the patient should rest,
elevate the involved ankle above the level of the heart, and apply ice, while keeping
the splint dry. If the injured leg is placed in a prefabricated splint able to withstand
ambulation, the patient may bear weight as tolerated. The importance of elevating
the leg should be emphasized to patients, as complications with splint treatment
often stem from allowing the foot to remain in a dependent position for too long.

Patients awaiting orthopedic consultation or surgery should remain

nonweightbearing in a splint (as described above), apply ice while keeping the
splint dry, and use pain medication as needed. If surgery is planned in the acute
setting, excessive use of narcotic analgesics should be avoided, if possible, until
the orthopedic surgeon is able to explain the procedure and obtain informed
consent. Management of specific fracture types is discussed immediately below.

Management of specific malleolar fractures — There is little high quality evidence

to determine the best treatment of ankle fractures [20]. Our recommendations
below are based upon limited randomized trials, observational data, and clinical
experience.  

Lateral malleolar fractures — Fracture stability determines treatment. The

location of an isolated lateral malleolar fracture in relationship to the joint can help
to determine if the fracture is stable. Lateral malleolar fractures below the level of
the tibiotalar joint line (ie, mortise) (image 14) are typically stable and less likely to
be associated with additional ligament injuries. When an ankle injury causes a
fracture above the level of the mortise (image 11 and image 12 and image 13), it is
typically unstable due to the associated syndesmosis injury and must be referred
for surgical evaluation. (See 'Indications for orthopedic consultation or referral'
above.)
The stability of fractures at the level of the mortise (image 4 and image 8 and
image 15) depends upon the integrity of the medial structures (mainly the deep
deltoid ligament and the medial malleolus) [14]. The presence of a lateral
malleolar fracture together with a medial fracture or deltoid ligament injury
significantly increases the risk of joint instability, even if alignment is well
maintained (image 7) [12].

Instability is demonstrated by 2 mm or more of displacement of the fibular

fracture, an associated medial fracture, or a medial ligament disruption, all of
which should prompt orthopedic referral (image 8). Medial swelling, ecchymosis,
and tenderness, suggests the possibility of medial ligament injury and requires
orthopedic consultation. Uncertainty about the stability of medial structures
indicates the need for stress radiographs, such as the gravity stress mortise view (
picture 1), to determine the degree of instability [15]. If medial instability is
demonstrated or suspected, orthopedic referral is obtained. If the medial
structures are intact and there is minimal fibular displacement, non-surgical
treatment has a high success rate [21,22]. Stress radiographs are described
above. (See 'Radiographic findings' above.)

Two long-term follow-up studies of patients with isolated lateral malleolar

fractures at or below the level of the ankle joint reported that greater than 90
percent of patients had good clinical results regardless of treatment, provided
fibular displacement did not exceed 3 mm [21,22]. Other studies comparing
operative with nonoperative treatment of isolated lateral malleolar fractures have
shown no significant difference in outcomes [5-7,9,23]. Based upon such studies,
treatment for isolated lateral malleolar fractures is primarily nonoperative.

If the fracture consists solely of a small, nondisplaced transverse avulsion

fragment, the patient may be treated like a patient with a severe ankle sprain, ie,
with early motion, bracing, and gradual rehabilitation (image 14). (See "Ankle
sprain".)
If the isolated fracture is oblique through the lateral malleolus at or below the
mortise, and there is no sign of instability, the patient may be treated in a short-leg
walking cast or removable cast boot, in neutral position, for three to six weeks,
weight-bearing as tolerated (image 15). Treatment in a removable cast boot
causes less discomfort and loss of mobility, and no change in long-term
outcomes, according to a small number of clinical trials [24]. The results of
another randomized trial suggest that immobilization for three weeks in a short-
leg walking cast or properly fitting rigid ankle orthosis further reduces the short-
term loss of ankle mobility and the risk for deep vein thrombosis compared with
treatment in a short-leg walking cast for six weeks, without compromising healing
[25]. While further study is needed to confirm the effectiveness of limiting
immobilization to three weeks, evidence in support of shorter periods of
immobilization is growing.

Radiographs should be repeated 7 to 10 days after the injury for oblique fractures
to ensure that alignment remains acceptable and again at four to six weeks to
assess healing [12]. An examination of the ankle, including palpation for medial
tenderness, should also be performed at these time intervals. In most cases,
healing can be assessed clinically. Once healing is evident (ie, nontender over the
fracture site with radiographic evidence of adequate callus around the fracture),
the patient may begin unsupported weight-bearing and gradual rehabilitation. If
healing is insufficient, the ankle should be immobilized or braced for an additional
two weeks and then reassessed. Persistent pain and a lack of callus formation
should prompt orthopedic referral.

Treatment of fractures of the proximal fibula and fibular shaft are discussed
elsewhere. (See "Fibula fractures".)

Isolated medial or posterior malleolar fractures — Care must be taken with

these fractures to confirm the absence of associated injuries. Fractures with
associated injuries, such as a proximal fibular fracture, are referred. If there is
concern for ligament injury in addition to the fracture, the patient should also be
referred for orthopedic consultation. If the fractures are truly nondisplaced,
isolated injuries, they can be treated initially in a splint (image 5). Patients should
not bear weight until their initial follow-up visit.

Seven to ten days following the injury, patients are re-evaluated, including repeat
radiographs to confirm alignment. If the isolated nature of the injury is confirmed
by examination and radiograph, the patient can be placed in a walking cast or
walking boot. The cast or boot should hold the ankle at 90 degrees to prevent a
flexion contracture.

Patients remain in the cast or boot, weight-bearing as tolerated, for four to six
weeks. Radiographs are repeated four weeks after the injury and subsequently
every two weeks until the fracture is clinically healed (ie, nontender over the
fracture site with radiographic evidence of adequate callus around the fracture).
Once clinically healed, patients should begin a gentle rehabilitation program.

Lateral malleolar fractures with deltoid ligament injury — A lateral malleolar

fracture with disruption of the deltoid ligament is unstable and is managed no
differently than a bimalleolar fracture (image 8). The instability associated with
these injuries has been confirmed in outcome studies and cadaveric research
models [12]. Anatomic reduction of the ankle with surgical stabilization leads to
better clinical results [12]. Patients with this injury should be splinted with the
ankle joint at 90 degrees, remain nonweightbearing, and be referred to an
orthopedist within a few days.

Bimalleolar and trimalleolar fractures — These fractures are unstable and

require operative fixation. Patients should be splinted with the ankle joint at 90
degrees, remain nonweightbearing, and be referred to an orthopedist within a few
days (image 7 and image 16).

REHABILITATION AFTER ANKLE FRACTURE

The goal of rehabilitation after an ankle fracture is to restore any loss of motion,
strength, or proprioception that may have occurred as a result of the injury or the
subsequent immobilization and disuse related to treatment. There is little
evidence that any specific rehabilitation program improves clinical outcome [9]. It
is possible that individuals may return to their preinjury level of activity more
quickly with aggressive rehabilitation. Research about early weight-bearing and
physical therapy is on-going. For most ankle fractures, rehabilitation can be carried
out with a basic home exercise program of stretching, range of motion,
strengthening, and balance exercises [26].

A systematic review of 38 controlled trials related to the rehabilitation of ankle

fractures found the evidence to be of limited quality and noted the following [27]:

● Early performance of ankle exercises following surgical fixation improved

ankle function and mobility, while decreasing pain, but was associated with
higher rates of adverse events (eg, surgical wound complications), although
most problems were minor. Use of a removable immobilization device was
necessary for this approach. For protocols involving early exercise, the authors
emphasized the importance of the patient’s ability to comply with the regimen
safely and precisely.

● Early ambulation following surgical repair may improve ankle motion, but
studies supporting this approach are small and contradictory.

● Neither stretching nor manual therapy (passive motion exercises performed by

a trained professional) appeared to improve function following the
immobilization period regardless of whether management was surgical or
conservative.

● Treatment with electrical or thermal stimulation devices or with ultrasound

was not supported by high quality evidence.
COMPLICATIONS

Ankle fractures have a relatively low complication rate when managed

appropriately in patients without comorbidities. Complication rates in patients with
significant comorbidities (eg, diabetes or peripheral vascular disease) or behaviors
known to impair fracture healing (eg, smoking) are higher [28,29]. (See 'Indications
for orthopedic consultation or referral' above and 'Treatment' above and "General
principles of fracture management: Early and late complications".)

Acute complications of ankle fractures, such as injuries to peripheral nerves or

vascular structures, open fractures, and compartment syndrome, are readily
identified in most cases and require immediate surgical consultation. Nerve injury
can occur at the time of injury from lacerations caused by fracture fragments,
direct contusion, or traction, but may also occur during subsequent treatment from
casting or splinting materials that compress the nerve. Injuries to the lateral ankle
or pressure on the proximal fibula from a cast or splint may lead to peroneal nerve
injury causing weak foot dorsiflexion; injuries to the medial ankle may lead to tibial
nerve injury. (See "Overview of lower extremity peripheral nerve syndromes",
section on 'Peroneal (fibular) nerve' and "Overview of lower extremity peripheral
nerve syndromes", section on 'Tibial nerve'.)  

Lower extremity compartment syndrome is less likely to occur from ankle

fractures than from fractures of the diaphysis of the tibia or fibula. Nevertheless,
any patient complaining of increasing pain or new numbness and tingling or other
symptoms concerning for compartment syndrome during treatment for an ankle
injury should be examined without delay. (See "Acute compartment syndrome of
the extremities", section on 'Clinical features'.)

Occasionally, skin damage can occur from stretching or abrasions incurred at the
time of injury or from subsequent splinting and casting. Blisters and abrasions
should be followed closely until they heal because of the risk of cellulitis.
Potential chronic complications of ankle fractures include instability,
osteoarthritis, and pain. Failure to recognize a syndesmotic injury that
accompanies a fibular fracture above the ankle joint may lead to instability and
premature osteoarthritis (image 17). In addition, a missed medial ligament injury
in the setting of a lateral malleolar fracture can lead to instability, which can
progress to joint pain and degeneration of the articular surface. While less than
five percent of patients with unimalleolar fractures develop degenerative changes,
detectable several years later by radiograph, as many as 20 percent of patients
with bimalleolar fractures develop such radiographic findings [9].

Nonunion or malunion of ankle fractures is uncommon in healthy patients.

Nevertheless, orthopedic referral is generally needed if a fracture does not appear
to be healing as expected by eight weeks following the injury. Inadequate healing
is suggested by persistent or worsening pain or tenderness at the fracture site, or
by signs of inadequate healing on plain radiographs. Orthopedic referral is
necessary if the fracture displaces during the course of treatment.

If functional deficits (eg, restricted motion) persist despite appropriate

management and rehabilitation, reevaluation for associated injuries, such as
ligament or tendon disruption, or osteochondral injury, should be performed.
Orthopedic consultation or imaging with MRI may be needed in such cases.

Complex regional pain syndrome (CRPS) may develop in the days or weeks
following an ankle fracture. Pain from CRPS is more severe than that expected
from the inciting injury and is often associated with such findings as abnormal
skin color, temperature change, diminished motor function, and edema (picture 2
and picture 3). Early identification and treatment of CRPS is important. (See
"Complex regional pain syndrome in adults: Pathogenesis, clinical manifestations,
and diagnosis", section on 'Clinical manifestations'.)

Diabetic patients have an increased risk of complications after ankle fracture

[12,28]. Skin injury, postoperative infection, and malunion occur more frequently in
diabetics. We suggest more frequent clinic visits (every two to three weeks),
including careful skin examination and radiographs, for these patients.

According to retrospective reviews, elderly patients generally have more complex

fracture patterns when compared to those under age 65 and are more prone to
postoperative complications [30,31]. However, overall functional outcomes among
patients above and below 65 years are similar when baseline function and the
complexity of the fracture are taken into account.  

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries

and regions around the world are provided separately. (See "Society guideline
links: Lower extremity (excluding hip) and pelvic fractures in adults".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, “The Basics” and
“Beyond the Basics.” The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or five key
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sophisticated, and more detailed. These articles are written at the 10th to 12th
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Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also locate
patient education articles on a variety of subjects by searching on “patient info”
and the keyword(s) of interest.)
 ● Basics topics (see "Patient education: Ankle fracture (The Basics)" and
"Patient education: Fractures (The Basics)" and "Patient education: Cast and
splint care (The Basics)" and "Patient education: Using crutches (The Basics)")

● Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond
the Basics)")

SUMMARY AND RECOMMENDATIONS

● Ankle fractures are common injuries. The vast majority of ankle fractures are
malleolar fractures; 60 to 70 percent are unimalleolar. Supination (inversion)
injuries typically cause distraction (stretching) of the lateral ankle structures
and compression of the medial structures. Pronation (eversion) injuries cause
medial distraction and lateral compression. Structures being distracted
generally fracture or tear before structures being compressed. (See
'Epidemiology and risk factors' above and 'Clinical anatomy' above and
'Mechanism of injury' above.)

● Open fractures and any injury with associated neurologic or vascular deficits
require immediate surgical referral. Fracture dislocations require rapid
reduction. (See 'Indications for orthopedic consultation or referral' above.)

● An ankle fracture, particularly one sustained in a fall, may mask other injuries.
Particularly with elderly patients and cases involving significant trauma, the
clinician should palpate the lumbar spine, the hip, the tibia and fibula,
especially the fibular neck, and the foot as part of the evaluation for possible
associated injuries. (See 'Clinical presentation and examination' above.)

● Once emergency conditions have been ruled out, the first priority in the
evaluation of ankle fractures is to determine whether the fracture is stable, and
can be managed nonoperatively, or unstable, and must be referred. Typically,
an ankle fracture is stable if it meets the following criteria:
 • It is isolated to the lateral, medial, or posterior malleolus.

• It is nondisplaced.

• It is not associated with a ligamentous injury.

● An ankle fracture is unstable if two or more sites of significant injury are

present, such as a lateral malleolar fracture with deltoid ligament disruption or
a bimalleolar fracture. (See 'Clinical presentation and examination' above and
'Indications for orthopedic consultation or referral' above.)

● The Ottawa ankle rules help to determine whether radiographs of the ankle or
foot are needed in the evaluation of an acute ankle injury (figure 8). Anterior-
posterior (AP), oblique, and lateral views are the standard views obtained if the
patient meets the Ottawa criteria. (See 'Radiographic findings' above.)

● Initial management of ankle fractures consists of splinting, ice, elevation above

the level of the heart, and analgesics. The ankle should be splinted at 90
degrees. Usually, a short-leg posterior splint is sufficient. (See 'Initial treatment'
above.)

● Unstable ankle fractures often require surgical repair. Management of the

major types of ankle fractures is discussed in the text. The goal of
rehabilitation after an ankle fracture is to restore any loss of motion, strength,
or proprioception that may have occurred. (See 'Management of specific
malleolar fractures' above and 'Rehabilitation after ankle fracture' above.)

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