II. Epidemiology

  1. Ankle Fractures account for 15% of acute ankle injuries

III. Classification: Weber

  1. Weber A (stable)
    1. Transverse fibula avulsion Fracture below syndesmosis and below talar dome and joint line
    2. May be associated with a medial malleolus Fracture (oblique or vertical) or medial deltoid ligament tear
    3. Syndesmosis intact, and nearly always stable (esp. if no medial malleolus Fracture)
  2. Weber B (may be unstable)
    1. Fracture at the level of the talar dome
    2. Oblique fibula Fracture (spiral Fracture) at syndesmosis
    3. May be accompanied by medial deltoid ligament tear or medial malleolus transverse avulsion Fracture
    4. May tear anterior tibiofibular ligament (lateral ankle)
    5. 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. Associated with Tibiofibular syndesmotic ligament rupture
    3. May be associated with transverse medial malleolus Fracture or medial Deltoid ligament rupture
  4. Images
    1. ankleFractureWeberABC.jpg
  5. References
    1. Hughes (1979) Clin Orthop Relat Res (138):111-9 +PMID:445892 [PubMed]

IV. Exam

  1. See Ankle Exam
  2. See Knee Exam
  3. See Foot Exam

VI. Signs and Symptoms

  1. Pain
  2. Swelling
  3. Inability to bear weight
  4. Significant deformity if dislocation present

VII. 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

VIII. 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

IX. 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

X. 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)

XI. Complications

  1. Ankle Osteoarthritis
    1. Likely if poorly aligned ankle mortise or talus position
    2. Fracture management shoul ensure smooth articular surface of ankle

XII. Prognosis

  1. Stable Fractures treated with non-operative, conservative therapy
    1. Return to baseline activity within 6-8 weeks is common
  2. Unstable Fractures requiring surgical intervention
    1. Weight bearing after surgery is often delayed up to 12-16 weeks
    2. Return to full functional capacity may require up to 2 years
  3. References
    1. Smeeing (2018) Eur J Trauma Emerg Surg 46(1): 121-30 [PubMed]

XIII. References

  1. Courtney and Shannon (2020) Crit Dec Emerg Med 34(5): 14-5
  2. Orman and Ramadorai in Herbert (2017) EM:Rap 17(1): 7-9

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Ankle Fractures (C0159877)

Definition (NCI) Traumatic or pathological injury to the ankle joint in which the continuity of an ankle bone is broken. Symptoms include pain, swelling, and difficulty moving the affected leg and foot.
Definition (NCI_CTCAE) A finding of damage to the ankle joint characterized by a break in the continuity of the ankle bone. Symptoms include marked discomfort, swelling and difficulty moving the affected leg and foot.
Concepts Injury or Poisoning (T037)
MSH D064386
ICD9 824
ICD10 S82.89
SnomedCT 208641007, 263243006, 208674007, 208656003, 157249007, 16114001
English Fracture of ankle, NOS, Frac distal end of tibia & fib, fracture of ankle, ankle fracture, ankle fx, fracture of ankle (diagnosis), Broken ankle, Fracture of ankle NOS, Fracture;ankle, ankle fractures, broken ankle, Ankle Fractures, Fracture, Ankle, Fractures, Ankle, Fracture of distal end of tibia and fibula (disorder), Fracture of ankle, NOS (disorder), Ankle Fractures [Disease/Finding], Fracture of ankle, Ankle fracture, Fracture of distal end of tibia and fibula, Fracture of ankle (disorder), fracture; ankle, ankle; fracture, Ankle Fracture, fractured ankle
Italian Frattura della caviglia, Fratture della caviglia
Dutch gebroken enkel, enkelfractuur, enkel; fractuur, fractuur; enkel, enkelbreuk
French Cheville cassée, Fracture de la cheville, Fractures de la cheville, Fracture de cheville
German gebrochener Knoechel, Bruch des Knoechels, Malleolarfrakturen, Sprunggelenkfrakturen, Knoechelfraktur
Portuguese Tornozelo partido, Fractura do tornozelo
Spanish Tobillo roto, fractura de tobillo, fractura de tobillo (trastorno), fractura del tobillo (trastorno), fractura de tobillo, SAI, fractura de tobillo, SAI (trastorno), Fracture of ankle, NOS, fractura del tobillo, Fractura de tobillo
Japanese 足関節部骨折, ソクカンセツブコッセツ, アシカンセツブコッセツ, ソッカンセツブコッセツ
Czech Zlomenina kotníku, Zlomený kotník, fraktury kotníku, kotník - zlomeniny
Hungarian Törött boka, Bokatörés

Ontology: Trimalleolar Fractures (C0435907)

Concepts Injury or Poisoning (T037)
MSH D064386
ICD10 S82.82
SnomedCT 157248004, 123975002
English Trimalleolar fracture of ankle, Trimalleolar fracture, ankle, trimalleolar ankle fracture, trimalleolar fracture, trimalleolar fracture of ankle, fracture trimalleolar, fractures trimalleolar, Fractures, Trimalleolar Ankle, Fractures, Trimalleolar, Trimalleolar Fractures, Fracture, Trimalleolar Ankle, Trimalleolar Ankle Fractures, Ankle Fracture, Trimalleolar, Fracture, Trimalleolar, Trimalleolar Fracture, Trimalleolar Ankle Fracture, Ankle Fractures, Trimalleolar, Trimalleolar fracture, Trimalleolar fracture (disorder), fracture; trimalleolar, trimalleolar; fracture
French Fractures trimalléolaires
German Trimalleolaere Sprunggelenksfrakturen, Trimalleolarfrakturen, Trimalleolaere Frakturen, Trimalleoläre Frakturen, Trimalleoläre Sprunggelenksfrakturen
Italian Fratture trimalleolari
Dutch fractuur; trimalleolair, trimalleolair; fractuur
Spanish fractura trimaleolar (trastorno), fractura trimaleolar

Ontology: Bimalleolar Fractures (C0435908)

Concepts Injury or Poisoning (T037)
MSH D064386
ICD10 S82.81
SnomedCT 157247009, 123974003, 263244000
English BIMALLEOLAR ANKLE FRACTURE, Frac medial and lat malleoli, Bimalleolar fracture, Bimalleolar fracture, ankle, ankle bimalleolar fractures, bimalleolar ankle fracture, ankle fracture pott's, bimalleolar fracture, Bimalleolar Fracture, Equivalent Fractures, Bimalleolar, Fracture, Bimalleolar, Bimalleolar Equivalent Ankle Fractures, Fractures, Bimalleolar Ankle, Bimalleolar Equivalent Fracture, Bimalleolar Ankle Fractures, Bimalleolar Fractures, Fractures, Bimalleolar Equivalent, Fractures, Bimalleolar, Ankle Fractures, Bimalleolar, Fracture, Bimalleolar Equivalent, Fracture, Bimalleolar Ankle, Ankle Fracture, Bimalleolar, Bimalleolar Equivalent Fractures, Equivalent Fracture, Bimalleolar, Bimalleolar Ankle Fracture, Bimalleolar fracture (disorder), Bimalleolar fracture of ankle, Fracture of medial and lateral malleoli, Bimalleolar fracture of ankle (disorder), bimalleolar; fracture, fracture; bimalleolar
Dutch bimalleolaire fractuur, bimalleolair; fractuur, fractuur; bimalleolair
French Fracture bimalléolaire, Équivalents de fractures bimalléolaires, Fractures bimalléolaires
German bimalleolaere Fraktur, Bimalleoläre Knöchelfrakturen, Bimalleolarfrakturen, Bimalleolaere Knoechelfrakturen, Bimalleolaere Frakturen, Bimalleoläre Frakturen, Bimalleoläre Sprunggelenksfrakturen, Bimalleolaere Sprunggelenksfrakturen
Italian Frattura bimalleolare, Fratture bimalleolari, Fratture bimalleolari della caviglia
Portuguese Fractura bimaleolar
Spanish Fractura bimaleolar, fractura bimaleolar (trastorno), fractura bimaleolar, fractura bimaleolar de tobillo (trastorno), fractura bimaleolar de tobillo
Japanese 足関節両果骨折, ソクカンセツリョウカコッセツ, アシカンセツリョウカコッセツ
Czech Bimaleolární fraktura
Hungarian Bimalleolaris törés