II. Epidemiology
- Ankle Fractures account for 15% of acute ankle injuries
III. Classification: Weber
- Weber A (stable)
- Weber B (may be unstable)
- Fracture at the level of the talar dome
- Oblique fibula Fracture (spiral Fracture) at syndesmosis
- May be accompanied by medial deltoid ligament tear or medial malleolus transverse avulsion Fracture
- May tear anterior tibiofibular ligament (lateral ankle)
- Syndesmosis is typically intact, but Fracture is often unstable (esp. if medial Deltoid ligament rupture)
- Weber C (unstable)
- Lateral malleolus fibula Fracture, above ATF ligament
- Associated with Tibiofibular syndesmotic ligament rupture
- May be associated with transverse medial malleolus Fracture or medial Deltoid ligament rupture
- Images
- References
IV. Exam
- See Ankle Exam
- See Knee Exam
- See Foot Exam
V. Differential Diagnosis
VI. Signs and Symptoms
- Pain
- Swelling
- Inability to bear weight
- Significant deformity if dislocation present
VII. Associated Conditions
- Fifth Metatarsal Fracture
- Maisonneuve Fracture (Proximal Fibula Fracture, rotational injury)
- Associated with Compartment Syndrome
- Lateral Talus Fracture
- CT ankle indicated for significant swelling at lateral talus despite negative xray
VIII. Imaging
-
Ankle XRay
- See Ankle XRay (consider xrays of foot and tibia-fibula)
- Instability findings
- Widening of ankle mortise (Weber C and some Weber B Fractures)
- Consistent with unstable Ankle Fracture
- Lateral talus displacement on gravity stress or external rotation (Weber B)
- Suggests Deltoid ligament rupture (and unstable Fracture)
- Widening of ankle mortise (Weber C and some Weber B Fractures)
- MRI foot indications
- Suspected Calcaneal Stress Fracture or Navicular Stress Fracture
IX. Management: Initial emergency department evaluation
-
General measures
- RICE-M Therapy
- Reduce Ankle Fracture-dislocation
- Emergent orthopedic evaluation and surgery
- Routine surgical management
- Indications
- Weber C Fracture
- Weber A Fracture with medial malleolus Fracture
- Trimalleolar Fracture
- Maisonneuve Fracture
- Weber B Fracture with instability (refer all Weber B Fractures to orthopedics for reevaluation)
- Findings suggestive of instability
- Ankle mortise wide
- Lateral talus displacement on gravity stress or external rotation
- Findings suggestive of stability (stable Fracture in 98% of cases if both criteria present)
- Posterior displacement of of distal Fracture fragment <2mm (on lateral XRay)
- Only two Fracture fragments
- Nortunen (2017) J Bone Joint Surg Am 99(6): 482-7 +PMID:28291180 [PubMed]
- Findings suggestive of instability
- Initial management
- Immobilize in fiberglass or plaster splint (sugar tong with or without posterior splint)
- Non-weight bearing
- Follow-up re-evaluation orthopedics for possible surgical management
- Weber B Fractures are indeterminate for surgical management until Stress Imaging
- ORIF may be performed in first day prior significant swelling, but otherwise after 6 days
- Indications
- Conservative Management
- Weber A Fracture without medial medial malleolus Fracture
- CAM Boot or hard-soled shoe
- Weight bearing as tolerated
- Fracture line may persist on xray despite asymptomatic patient (no management required)
- Distal fibular chip Fracture (ATF or CF Ligament avulsion Fracture)
- Treat with Ankle Sprain Management
- Weber A Fracture without medial medial malleolus Fracture
X. Management: Weber-based protocol
- Surgical management (ORIF) Indications (disrupted ankle mortise)
- Non-surgical, conservate management
- Weber B Fracture with stable ankle mortise
- Weber A Fracture (stable Fracture)
XI. Complications
- Ankle Osteoarthritis
- Likely if poorly aligned ankle mortise or talus position
- Fracture management shoul ensure smooth articular surface of ankle
XII. Prognosis
- Stable Fractures treated with non-operative, conservative therapy
- Return to baseline activity within 6-8 weeks is common
- Unstable Fractures requiring surgical intervention
- Weight bearing after surgery is often delayed up to 12-16 weeks
- Return to full functional capacity may require up to 2 years
- References
XIII. References
- Courtney and Shannon (2020) Crit Dec Emerg Med 34(5): 14-5
- Orman and Ramadorai in Herbert (2017) EM:Rap 17(1): 7-9
Images: Related links to external sites (from Bing)
Related Studies
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 |
Russian | LODYZHKI TRESHCHINA, ЛОДЫЖКИ ПЕРЕЛОМЫ, ЛОДЫЖКИ ТРЕЩИНА, LODYZHKI PERELOMY |
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 |