Have you ever fractured your ankle or do you think you might have recently? Ankle fractures, also known as broken ankles, happen when one or more of the bones that make up the ankle joint are broken or compromised. These fractures, or breaks, can happen in many different ways, and sometimes, based on severity, they might need surgery.

Today, we’re going to talk about ankle fractures, and how you can be certain if you have broken your ankle or not, based on your symptoms and signs. We’ll also cover other treatment options that might be available to you based on the severity of your fracture. 

To understand ankle fracture surgery in-depth, we must look at the anatomy of an ankle. The ankle is made up of three different bones:

• The tibia (otherwise known as the shin bone), which forms the inside, front, and back of the ankle
• The fibula, which forms the outside of the ankle
• The talus, which is a small bone that sits between the tibia and fibula and the heel bone

While not a bone itself, each of these bones has ends which are called malleoli. These are bones that are typically broken when an ankle fracture occurs.

Type of ankle fractures

Based on these three bones and their malleoli, there are different types of ankle fractures that can occur. First of all, there are two overarching categories: stable and unstable fractures. Here is the difference between these two:

• Stable: A stable fracture is when the bone is broken but the ankle joint is still in position and the leg is stable. These types of fractures are usually treated with a boot or walking cast instead of surgery.
• Unstable: An unstable fracture is when the bone is broken and the ankle joint has shifted out of place, which affects the stability of the joint and leg. These are the types of fractures that usually require surgery.

Beyond these two categories, there are five common types of ankle fractures that can occur:

• Fibula Only Fracture: This is the most common type of ankle fracture and relates to the fibula bone only. This bone forms a lump on the outside of your foot and can break from twisting your ankle, being impacted on the outside of your leg, sports injuries, a bad landing, repetitive stress from activities and more. When you think of a broken ankle, this is usually what you are thinking of because of how common it is.

• Bimalleolar Ankle Fracture: This is the second most common type of ankle fracture. In this type, the fibula and the base of the tibia are both impacted. Most of the time, these are very serious injuries and are the result of high-impact accidents like falls, car accidents or a serious twist.

• Trimalleolar Fractures: This is the most severe type of ankle fracture. When this type of fracture occurs, the back of the tibia is broken off. This is usually caused by a high-impact accident.

• Tibia Only Fracture: Much like the last two, tibia only fractures are caused by high-impact accidents. The tibia bone can be broken in one place or can be shattered in several. 
• Maisonneuve Fracture: Often misdiagnosed as an ankle sprain, a Maisonneuve fracture is a fracture in the fibula, up closer to your knee than to the ankle joint. Even though the fracture is higher up and not very close to the ankle, the pain is usually felt in the ankle, making the leg feel unstable. This fracture will not be shown on an ankle X-ray since it is higher up, hence why it is often misdiagnosed.

Common causes

As mentioned above, there are some very common causes of ankle fractures. While these definitely are not the only possible causes, these are are a few we see the most often:

• Twisting or rotating the ankle: Sometimes, a twist of the ankle can be done on a low scale, such as taking a bad step on unsteady ground. Other times, this twist can be caused by a high-impact accident, like a fall. Either way, when the ankle is twisted or rotated at high speed and force, the ligaments in your ankle get stretched out and pull on the bone. This stress can cause a fracture in the bones or can even tear a chunk of the bone out. Depending on the severity, along with the speed and force, the fracture can range from common to severe.

• High-impact accidents/car accidents: If the ankle joint is impacted hard enough, the bone can crack under the pressure. Most often, this happens when the outside of the leg is hit at a high impact, causing them to break and potentially shift out of place. This might be during a car accident, a heavy fall on the side of the body, or your leg getting directly hit by a heavy object, machinery or heavy door. 
• Repetitive stress: Another common way that an ankle can be fractured is if it is being used in a repetitive way, causing stress. If you are already feeling ankle pain and you continue to walk, run, hike, dance, or otherwise move on it, a fracture can occur. Pain is usually a sign that your body needs you to stop, so we don’t encourage you to continue to move on a limb that is giving you pain without working with your doctor or a physical therapist. 

Symptoms

When it comes to ankle fracture symptoms, some will be very obvious while some others might be difficult to diagnose. Everyone experiences pain differently, so some of these may be present while others won’t be. Here are the most common symptoms we see:

• Immediate or throbbing pain
• Pain while walking or putting pressure on the ankle
• Swelling
• Discoloration
• Bruising
• Tenderness
• Deformity, bumps or protruding bone
• Tender to the touch or problem moving the ankle
• In extreme cases, the bones of the ankle may poke through your skin, which is called an open ankle fracture.

If you have an accident or twist your ankle and are feeling or experiencing any of the symptoms above, we encourage you to reach out to your orthopedic doctor right away. While sometimes these symptoms may be paired with simple sprains, it is important you take the time to be sure. Sometimes, if the pain is minimal or bearable, you may want to wait and see if it improves, but we still encourage you to call your doctor to get their professional opinion.

Obviously, if your symptoms are extreme, you should head to the doctor immediately. Your doctor can walk you through a diagnosis, discuss your treatment options, advise if you should have X-Rays done, and help you with your injury. Depending on the severity and which bones were affected, your doctor will lead you into different treatment options and let you know if you will likely need surgery or not. Next, we’re going to discuss the different treatment options that might be available for you, depending on the bones fractured and the severity of your accident.

Diagnosis

When you first arrive, your doctor will check your ankle for points of tenderness, swelling, bruising and deformities. Then, they will probably attempt to move your foot to test your mobility. This may hurt, but is important for your doctor to do. You may even be asked to walk around so the doctor can examine your form. If your symptoms make it seem like you have broken or fractured your ankle, your doctor will move on to testing. Here are the most common tests they will use:

• X-rays: Most fractures are able to be seen on x-rays, so this is likely the first step in your diagnosis. If the fracture is small, like a stress fracture, they may not appear on an X-Ray, or at least be hard to see.

• Bone scan: A bone scan is done by injecting a small amount of radioactive material under your skin. This material highlights bone irregularities, especially if your bone is broken. In the scan, there will be a bright spot showing where the break is.

• Magnetic resonance imaging (MRI): MRIs are important for testing because they can show the ligaments and bones by using radio waves and a strong magnetic field.
• Computerized tomography (CT): CTs use X-rays to compare and make cross-sectional images of your body. This will help your doctor see a more detailed image of the injured bone and the soft tissues around it. 

After your diagnosis, your doctor will move onto your treatment.

Treatment

In order to treat an ankle fracture, your doctor will assess the severity of the break. Once this is done, they can decide whether surgery is necessary or not. 

If you do not need surgery, your doctor will most likely:

• Recommend an over-the-counter pain reliever
• Offer a boot or walking cast for an allotted amount of time
• Recommend physical therapy for when the bone has fully healed. This will help you loosen your stiff muscles and ligaments in your ankles and feet, due to the accident and from the cast or boot.

If you do need surgery, your doctor will most likely:

• Recommend an over-the-counter pain reliever
• Reduction: If you have an unstable or displaced fracture, meaning the two ends of the fracture are not aligned or stable, your doctor will need to perform a reduction. Because of the pain or swelling you have, a muscle relaxer, sedative, or local anesthetic may need to be used. Basically, your doctor will need to manipulate the two pieces back together.
• Surgery: In severe cases, your orthopedic surgeon may need to use pins, screws, or plates to repair the broken bones and put them back into place. 
• Offer a boot or walking cast for an allotted amount of time after the surgery.
• Recommend physical therapy for when the bone has fully healed. This will help you loosen your stiff muscles and ligaments in your ankles and feet, due to the accident and from the cast or boot.

Risks

Every surgery comes with risks, whether they are uncommon or not. Much like other surgeries, ankle replacement surgery has a few inherent risks that your doctor may warn you of before your procedure. Here are a few risks that come with ankle replacement surgery specifically:

• Inherent risks associated with all surgeries like anesthesia risks, infection, damage to nerves and blood vessels, and bleeding or blood clots.
• Long term ankle joint stiffness
• Long term ankle weakness
• Arthritis caused by surgery

Beyond the risks related to surgery, there are some complications often brought on by fracturing an ankle bone itself. These are risks that might not reveal themselves until much later in your life, or can reveal themselves within weeks. While these are all uncommon, here are a few risks related to the breaking of your ankle bone:

• Arthritis: Even years later, arthritis can be caused by a previously broken bone
• Compartment syndrome: This condition is very rare for ankle injuries, but can happen. Compartment syndrome causes swelling, pain and sometimes even disability in muscles of the leg.
• Blood vessel or nerve damage: Ankle trauma can cause nerves and blood vessels injury, and potentially can even tear them. A symptom of this is numbness or circulation issues.

If you need help diagnosing and treating an ankle injury, you should get in touch with a podiatrist immediately. We encourage you to reach out as soon as you can, whether you think your injury is severe or even a sprain. Discussing your unique situation with a podiatrist can bring you the relief and care you need. Dr. Nilin M. Rao from Integrated Orthopedic has comprehensive training, which includes the diagnosis and treatment of ankle injuries, ankle fractures and ankle fracture surgery.

We encourage you to reach out after any ankle injury, so he can walk you through your next steps, based on your situation and the severity. If you are interested in booking an appointment with Integrated Orthopedics and Dr. Rao, feel free to reach out to us.