Ankle Fracture

Aka: Ankle Fracture, Ankle Fracture Weber Classification, Bimalleolar Fracture, Trimalleolar Fracture, Tibia-Fibula Fracture, Tib-Fib Fracture, Weber A Fracture, Weber B Fracture, Weber C Fracture

1. Classification: Weber
   1. Weber A (stable)
      1. Transverse fibula avulsion Fracture below syndesmosis and below joint line (or parallel)
      2. May be associated with a medial malleolus Fracture (oblique or vertical)
      3. Syndesmosis intact, and nearly always stable (esp. if no medial malleolus Fracture)
   2. Weber B (may be unstable)
      1. Oblique fibula Fracture at syndesmosis
      2. May be accompanied by medial deltoid ligament tear or medial malleolus transverse avulsion Fracture
      3. May tear anterior tibiofibular ligament (lateral ankle)
      4. Syndesmosis is typically intact, but Fracture is often unstable (esp. if medial Deltoid ligament rupture)
   3. Weber C (unstable)
      1. Lateral malleolus fibula Fracture, above ATF ligament
      2. Syndesmotic ligament rupture
      3. May be associated with transverse medial malleolus Fracture or medial Deltoid ligament rupture
   4. References
      1. Hughes (1979) Clin Orthop Relat Res (138):111-9 +PMID:445892 [PubMed]
2. Exam
   1. See Ankle Exam
   2. See Knee Exam
   3. See Foot Exam
3. Differential Diagnosis
   1. Pott's Fracture of the Ankle
   2. Talar Dome Fracture
   3. Posterior Talar Fracture
   4. Lateral Talar Fracture
   5. Ankle Sprain
4. Signs and Symptoms
   1. Pain
   2. Swelling
   3. Inability to bear weight
   4. Significant deformity if dislocation present
5. Associated Conditions
   1. Fifth Metatarsal Fracture
   2. Maisonneuve Fracture (Proximal Fibula Fracture, rotational injury)
      1. Associated with Compartment Syndrome
   3. Lateral Talus Fracture
      1. CT ankle indicated for significant swelling at lateral talus despite negative xray
6. Imaging
   1. Ankle XRay
      1. See Ankle XRay (consider xrays of foot and tibia-fibula)
      2. Instability findings
         1. Widening of ankle mortise (Weber C and some Weber B Fractures)
            1. Consistent with unstable Ankle Fracture
         2. Lateral talus displacement on gravity stress or external rotation (Weber B)
            1. Suggests Deltoid ligament rupture (and unstable Fracture)
   2. MRI foot indications
      1. Suspected Calcaneal Stress Fracture or Navicular Stress Fracture
7. Management: Initial emergency department evaluation
   1. General measures
      1. RICE-M Therapy
   2. Reduce Ankle Fracture-dislocation
      1. Apply inline traction while Splinting (Quigley maneuver pulls great toe up and medially)
      2. Most Fractures requiring reduction will need surgical management
   3. Emergent orthopedic evaluation and surgery
      1. Open Fracture
      2. Neurovascular compromise
      3. Non-reducible Fracture
   4. Routine surgical management
      1. Indications
         1. Weber C Fracture
         2. Weber A Fracture with medial malleolus Fracture
         3. Trimalleolar Fracture
         4. Maisonneuve Fracture
         5. Weber B Fracture with instability (refer all Weber B Fractures to orthopedics for reevaluation)
            1. Findings suggestive of instability
               1. Ankle mortise wide
               2. Lateral talus displacement on gravity stress or external rotation
            2. Findings suggestive of stability (stable Fracture in 98% of cases if both criteria present)
               1. Posterior displacement of of distal Fracture fragment <2mm (on lateral XRay)
               2. Only two Fracture fragments
               3. Nortunen (2017) J Bone Joint Surg Am 99(6): 482-7 +PMID:28291180 [PubMed]
      2. Initial management
         1. Immobilize in fiberglass or plaster splint (sugar tong with or without posterior splint)
         2. Non-weight bearing
      3. Follow-up re-evaluation orthopedics for possible surgical management
         1. Weber B Fractures are indeterminate for surgical management until Stress Imaging
         2. ORIF may be performed in first day prior significant swelling, but otherwise after 6 days
   5. Conservative Management
      1. Weber A Fracture without medial medial malleolus Fracture
         1. CAM Boot or hard-soled shoe
         2. Weight bearing as tolerated
         3. Fracture line may persist on xray despite asymptomatic patient (no management required)
      2. Distal fibular chip Fracture (ATF or CF Ligament avulsion Fracture)
         1. Treat with Ankle Sprain Management
8. Management: Weber-based protocol
   1. Surgical management (ORIF) Indications (disrupted ankle mortise)
      1. Weber A Fracture WITH medial maleolus vertical Fracture
      2. Weber B Fracture with instability
         1. Ankle mortise wide
         2. Lateral talus displacement on gravity stress or external rotation
      3. Weber C Fracture (all)
      4. Trimalleolar Fracture
      5. Maisonneuve Fracture
   2. Non-surgical, conservate management
      1. Weber B Fracture with stable ankle mortise
      2. Weber A Fracture (stable Fracture)
9. Complications
   1. Ankle Osteoarthritis
      1. Likely if poorly aligned ankle mortise or talus position
      2. Fracture management shoul ensure smooth articular surface of ankle
10. References
    1. Orman and Ramadorai in Herbert (2017) EM:Rap 17(1): 7-9