Ankle Fracture

Introduction

An ankle fracture is a break of a bone in the ankle. The ankle consists of three bones that come together so any one of these may be broken.

Ankle anatomy

The ankle bone is called the talus. The top of the talus fits inside a socket that is formed by the lower end of the tibia (shinbone) and the fibula the small bone of the lower leg). The bottom of the talus sits on the heelbone, called the calcaneus.

Causes

A fracture occurs when the ankle is stressed beyond the strength of its elements. Commonly this happens by rolling the ankle in or out, twisting the ankle side to side or extreme flexing or extending of the joint as well as severe force applied to the joint by coming straight down on it as in jumping from a high level. Ligaments can also be torn at the same time.

A fractured ankle can range from a simple break in one bone, which may not stop you from walking, to several fractures, which forces the ankle out of place and may require that you not put weight on it for three months. The more bones that are broken, the more unstable the ankle becomes.
Symptoms

A broken ankle is painful and becomes swollen straight after the injury. It’s also very difficult to walk on and in severe fractures, the bones may stick out at an angle. Anyone with a suspected fractured ankle should see a doctor as soon as possible who will usually confirm the fracture with an X-ray.

It’s best to stay off the injured ankle to prevent further injury and keep the ankle elevated to help decrease swelling and pain. Cold packs can also be applied to the injured area to reduce swelling and pain. An anti-inflammatory pain killer such as Ibuprofen is also ideal for ankle injuries because it acts as both a pain killer and reduces the inflammation.

Treatment

Some minor ankle fractures can be managed like an ankle sprain and don’t need casting or surgery. These fractures tend to heal well because they are small.

Other ankle fractures may need treating with splint, cast or surgery. In these cases, Mr Hull will first place a splint (rigid support) on your injured ankle for a few days to two weeks until the swelling decreases around the joint. After the swelling decreases then Mr Hull may place a better-fitting cast on your lower leg and foot.

If the ankle bones are not aligned properly, Mr Hull may have to realign them before the splint is applied. If this is the case, you will be given painkillers and a sedative to help you relax and minimize any pain.

If the bones cannot be realigned properly then you may need an operation. MR Hull may also decide that surgery is appropriate if any bone has broken through the skin (compound fracture).

Surgery

More severe fractures are likely to need surgery. First of all you will be given a general anaesthetic so that you are unconscious during the operation.

Mr Hull will then make a cut in the skin in one or both sides of your ankle so the pieces of bone can be brought together. Screws and plates may be used to hold the bones together, and the wound is closed using stitches.

This procedure is called open reduction and the screws and plates are usually left in.

Risks and complications

As with all operations, there is a possibility of a reaction to the anaesthetic, excessive bleeding, developing a blood clot and wound infection. A general anaesthetic may also make you feel temporarily sick after the operation.

There are also a number of specific possible complications related to ankle fractures. In some cases there may poor wound healing and reduced movement of the ankle. Ankle fractures involving the growth plate in children can lead to deformity and growth disturbance. Nerves in the area may also be injured which can cause some numbness.

Arthritis in later life is one of the most common long-term complications affecting a broken ankle. When bones around the joint have broken they are likely to undergo more severe wear and tear than non-injured joints. Ultimately this can lead to pain and inflammation in the joint which may need further treatment.

Compartment syndrome is another possibility, which occurs due to increased pressure within a confined space, or compartment, in the body. If this happens, you may need further surgery to relieve the pressure.

Preparing for surgery

Mr Hull will talk to you about how best to prepare for surgery which may include stopping taking any anti-inflammatory medications such as aspirin to reduce the risk of blood clots and stopping smoking if you are a smoker to minimize the risk of infection.

If you're having a general anaesthetic, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand.

Mr Hull may also ask you to wear compression stockings to help prevent blood clots forming in the veins in your legs or may give you an injection of an anti-clotting medicine called heparin to help prevent blood clots forming in the veins in your legs. You will usually be put on an antibiotic drip before surgery. This is to reduce your risk of getting an infection during surgery.

Recovery

After the operation, you will need to rest until the effects of the anaesthetic have worn off. Mild to moderate pain should be expected immediately following ankle surgery which can be remedied with non-prescription pain killers.

To reduce pain and inflammation, Mr Hull may recommend an over-the-counter pain reliever but if you're experiencing severe pain, you may need an opioid medication, such as codeine.

It usually takes about four to eight weeks for the bones to heal completely, longer if surgery is needed, and up to several months to regain full use and range of motion of the joint.

How soon you can return to work depends on how badly you fractured the ankle and the type of work you do, but you will probably be off for quite a few weeks.

It’s important to follow Mr Hull’s advice which is likely to include resting your leg raised for the two weeks following open surgery.

When Mr Hull says you can start moving your ankle, you will be given physical therapy and home exercise which you will need to do regularly.

Eventually, you will also start doing strengthening exercises. 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.

Once the fracture has healed, MR Hull may recommend that you wear an ankle brace for several months while you are doing sporting activities.

Further information

For further information please contact Mr Peter Hull FRCS, Consultant Trauma & Orthopaedic Surgeon.