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Ankle fracture

Background

Overview

Definition
Ankle fractures refer to a fracture in any of the three bones comprising the ankle joint: the lateral or posterior malleolus of the tibia, medial malleolus of the fibula, and/or the talus.
1
Pathophysiology
Common causes of ankle fractures include trauma from falls, sports injuries, and twisting of the ankle. The primary mechanisms of ankle fractures are rotational injuries and supination or pronation movements.
2
Disease course
Clinically, patients with ankle fractures often present with pain, swelling, and bruising in the ankle area. They may also have difficulty bearing weight on the affected side.
1
Prognosis and risk of recurrence
The prognosis of ankle fractures can vary based on the severity of the fracture and the patient's adherence to rehabilitation. Complications such as posttraumatic arthritis or chronic instability can occur. In some cases, surgical intervention may be required, particularly for complex fractures.
3

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of ankle fracture are prepared by our editorial team based on guidelines from the Surgical Infection Society Europe (SIS-E/GAIS/WSES/WSIS/AAST 2024), the Eastern Association for the Surgery of Trauma (EAST/AOTA 2023), the American College of Radiology (ACR 2020), the British Medical Journal (BMJ 2017), the American Academy of Family Physicians (AAFP 2016,2012), ...
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Classification and risk stratification

Ottawa ankle rule: as per AAFP 2012 guidelines, use the Ottawa Ankle Rule to rule out fractures and prevent unnecessary radiographs in patients with suspected ankle sprain.
A
Ottawa Ankle Rule
Pain in malleolar zone
Pain in midfoot zone
Tenderness at posterior edge or tip of lateral malleolus
Tenderness at posterior edge or tip of medial malleolus
Tenderness at the base of 5th metatarsal bone
Tenderness at navicular bone
Inability to bear weight both immediately and in emergency department
Ankle X-ray not required
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Diagnostic investigations

History and physical examination
As per BOA 2016 guidelines:
Assess for the mechanism of injury and clinical findings, including skin integrity, circulation, and sensation at presentation.
E
Assess for comorbidities that might influence treatment choice and outcome, including preexisting mobility impairment, diabetes mellitus, peripheral neuropathy, peripheral vascular disease, osteoporosis, renal disease, smoking, and alcohol abuse.
E

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  • Ankle imaging

  • Foot imaging

  • Leg imaging

Medical management

Pain management
As per AOTA/EAST 2023 guidelines:
Consider administering NSAIDs (such as ketorolac) for pain management in adult patients with a traumatic fracture.
C
Insufficient evidence to recommend the preferential use of either selective NSAIDs (COX-2 inhibitors) or nonselective NSAIDs.
I

Therapeutic procedures

Reduction and splinting: as per BOA 2016 guidelines, offer analgesia and splinting and allow bearing weight as tolerated in patients with a stable ankle fracture. Avoid obtaining further follow-up.
E
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Perioperative care

Perioperative antibiotics
As per AAST/GAIS/SIS-E/WSES/WSIS 2024 guidelines:
Administer antibiotic prophylaxis as soon as possible to reduce wound infections in open fractures.
B
Do not administer long-term antibiotic therapy (7-10 days) to reduce open fracture wound infection rate.
D

Surgical interventions

Indications for surgery
As per BOA 2016 guidelines:
Perform surgery to achieve reduction and stabilization of the ankle mortise. Assess the syndesmosis and stabilize if unstable. Obtain intraoperative radiographs to confirm reduction.
E
Perform early fixation (on the day or day after injury) in most patients aged < 60 years with unstable ankle mortise. Consider performing external fixation in case of gross instability associated with soft tissue compromise.
E

Follow-up and surveillance

Follow-up
As per BOA 2016 guidelines:
Review patients within 2 weeks with further radiographs (weight bearing if possible) to confirm the position remains acceptable in fracture patterns where stability is uncertain.
E
Follow-up patients after surgery within 6 weeks of surgery to detect complications and confirm maintenance of reduction on radiographs.
E

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