Introduction and anatomy

fractures of the ankle means broken bones involved in the composition of ankle joint and also ligaments
the ankle joint is consists of three bones which are the two bones of the leg( lower end of  tibia by its medial malleolus  and and lower end of the fibula by its lateral malleolus) and the talus bone by its body which is bone of the foot the ankle joint is hinge joint  like any hinge joint it is become weak anterior (infront ) and posterior (from the back)and strong laterally (from outside) and medially( from inside) by it is ligaments attachment
The ligaments responsible for stability of the ankle are
Inferior tibiofibular ligaments (anterior and posterior ) also called(syndesmosis joint) these connect the fibula to the tibia along with a weak interosseous membrane

Lateral ligament which is weak ligament and is the most common ligament to torn it arise from the fibula 
and consists of three parts anterior and posterior slip and attached to the talus bone and central slip attached to the calcaneus bone

Medial ligament or deltoid ligament it is most strong one so it is rare to torn it is triangular in shape which arise from the medial malleolus of the tibial bone and distally it is deep fibres attached to the medial surface of the talus bone and the superficial fibres attach to navicular bone ,and to spring ligament and calcaneus bone

There are two types of movement in the ankle joint either

  inversion (look toward inside) eversion (look toward outside
Ankle sprains
   Definition of sprains its means tear or stretching injury of the ligaments  which  support the joints and attached to the bones which may be partial or complete tear which is differs from strains which means tear or stretching injury of the muscle or tendon attached to the bones The sprains may be mild or moderate or severe mild sprains as just stretching of the ligament moderate sprains means partial tear of the ligament severe sprains means complete tear of the ligament

Clinical features

 pain either mild or moderate or severe patient may hear pop sound or feel tear in the affected joint swelling bruising patient may complains from joint instability by  unable to walking well or unable to put the foot on the ground well
  • Minor trauma may causing ankle sprains which is most Common ankle injuries result from an inversion force like Twisting or rotating the ankle inside leads to torn or injuries lateral collateral ligament complex
  • Common in athletes dancing sporting people
Ankle fractues
  • Twisting or rotating injuries of the ankle
  • Most common mechanism when the foot supinated and the ankle external rotated
  • When foot fixed on the ground and the leg rotated
  • Severe injuries associated with subluxation or dislocation of the ankle joint
  • Impact or rolling the ankle
  • Motor car accident and fall from high
Classifications of ankle fractures

There are many types of classifications of ankle fractures but there are two types which widely used they are Weber-AO system which depend on the level of the fibula fractures and the Lange - Hansen system which refers to the position of the foot and the direction of the deformity force
In the Weber - AO system fractures are classified by the the level of the lateral malleolar injury(fiblula fracture) as follow
Type A fractures of the fibula are below the tibial plafond and are typically transverse fractures
Type B  fractures of the fibula begins at the level of the tibial plafond and typically extend proximally in a spinal or short oblique fashion
Type C fractures of the fibula are initiated above the tibial plafond and are associated with syndesmostic injuries
Clinical feature
  • Sever pain
  • Bruising and swelling with tenderness indicated the site of injury
  • Deformity if present suggestive ankle dislocation or major soft tissue injury
  • Neurovascular injury less common but need to be exclude
  • Severe swelling and fractures blisters can appear at an early stage which may delay surgical treatment
  • Take care patient with ankle swelling and tenderness suggestive of a fractures but has negative ankle radiographs should be search for high fibular tenderness which may indicated unstable ankle injury
  • The patient unable to walking or can not put his leg on the ground
 History taking to know the source of injury and it occur either motor car or just twisting and also ask about patient symptoms what he or she feels and the site of pain and if there is family or present history of associated medical diseases like diabetes or other chronic illness
Imaging study
Plain X rays which is most  common used easy and simple to see the site of fractures and it is types either posteroanterior or lateral or oblique views and also used to classified the ankle fractures types as in the Danis weber classification which related to level of the fibular fracture
CT scan may be needed in case of injuries extended to ankle joint
MRI scan may be needed to evaluate the ligaments injuries of the ankle
Stress radiographs  or plain X rays test  may required to confirm the stability of ankle fractures
Treatment of ankle sprains
Minor sprains treated by rest  ice packs and compression bandaging and elevation and progressive exercise programme
Sever sprains treated by cast for 2 weeks to allow the pain to settle before starting to mobilize
simple analgesic as non steroidal anti-inflammatory drugs to relieve the pain as indomethacin
in case of isolated medial or deltoid ligament sprain  it must be check for associated high fibular fracture and diastasis at the distal tibia-fibular joint Maisonneuve fracture which may need internal fixation
in case of high ankle sprain or syndesmotic injury may need also surgical treatment
Treatment of ankle fractures
Aims of the treatment are 
  •  To restore and maintain normal alignment of the talus with the fiblua
  • To ensure no future problems with unstability
  • To avoid secondary osteoarthritis
Conservative treatment
Indicated in case of simple undisplaced stable one malleolar  fractures some displaced fractures treated by manual reduction and cast immobilization for 6 weeks
Surgical treatment
  • Fractures shaft of talus bone or potential talar shaft
  • Fibular fractures above the inferior tibiofibular joint
  • Displaced medial malleolus
  • shortening of the fibula
  • Displaced articular fragments
  • all types of unstable injuries
Treated by open reduction and internal fixation
as any fractures beside wound leakage and infection secondary to severe swelling in the early phase
post-traumatic arthritis can cause severe disability for more see the articles of complications of bones fractures

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