Treatment of ankle fractures

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Why is precise ankle fracture alignment important?

Ankle fractures are fractures that occur within the distal epiphysis of the tibia and / or the fibula and contribute to the formation of the ankle joint. The ankle joint, or the upper ankle joint, consists of the articular surfaces:

the upper articular surface of the talus bone and the inferior articular surface of the tibia,
the medial articular surface of the talus block and the articular surface of the medial ankle (tibia),
the lateral articular surface of the ankle block and the articular surface of the lateral ankle (arrows).
The fibula and the tibia form a fork between which the talus bone is located. The posterior edge of the tibia is sometimes referred to as the "third ankle" and fractures in which it is involved are known as tri-bone fractures. Mutual correct positioning of the bones of the shin and the talus allows the articular surfaces to be closely matched to each other (the so-called joint congureency) and thus evenly distributing the load transferred to the talus.

Ankle fractures may lead to a disturbance of the above-mentioned anatomical relations, which changes the distribution of forces acting on the ankle bone and generates points of increased pressure in the area of ​​the ankle joint cartilage. The aim of the treatment of ankle fractures is the precise reconstruction of all articular surfaces while maintaining their correct alignment until the bones fully heal. Otherwise, failure to achieve joint congruence may result in faster degeneration of the articular cartilage and premature development of a degenerative disease (arthrosis).

Types of ankle fractures

There are several classifications of ankle fractures. The most popular of these are the Danis-Weber and Lauge-Hansen classifications. These classifications are based on the mechanism of fracture formation, the fracture level of the lateral ankle, and hence the method of donation. Due to their length, they will not be discussed here. In simple terms, ankle fractures can be described as below:

Fracture of the lateral ankle
The fibula carries 1/6 of the loads on the ankle joint. Fracture of the fibula may lead to its shortening and positioning in external rotation. Precise alignment of the fracture of the ankle is very important, because even a slight deviation from its correct positioning seriously disturbs the congureency of the ankle joint.

Fracture of the lateral ankle with damage to the tibiofibular ligament
The tibiofibular ligament connects the tibia and the arrow in their lower section. Damage to the ligamentous joint can cause widening of the ankle forks and cause instability of the ankle joint.

Fracture of the medial ankle, double wedge fractures
The medial malleolus rarely fractures isolated. The most common fractures of the tibia and fibula are simultaneous.

Trilateral fracture
A triadic fracture involves the simultaneous fracture of the lateral malleolus, medial malleolus, and the posterior edge of the tibia (the "posterior ankle"). The fracture may be accompanied by posterior talus dislocation and tearing of the tibiofibular ligament.

Fracture "pilon fracture"
The term "pilon" refers to the distal end of the tibia resulting from high-energy injuries - most often falls from a height. They are multi-fragmented fractures with complete separation of the ankle joint from the tibia. They are accompanied by severe trauma to the soft tissues surrounding the ankle joint.

Fractures of ankles in children

Children have two characteristic fractures: Tillaux and three-plane fractures that can involve tibial growth cartilage. A very important goal of treatment is to protect the growth cartilage, the permanent damage of which could lead to disturbances in bone growth along the length.

Treatment of ankle fractures

When choosing the method of treatment, one should take into account not only the type of fracture, but also factors such as:

the presence of acute cartilage or cartilaginous lesions of the ankle joint,
the presence of comorbidities affecting the healing processes (varicose veins, atherosclerosis of the arteries of the lower extremities, diabetes),
the patient's age, level of activity,
type of sports activity (the more active and demanding the patient, the closer we are to operational decisions that give a chance for an early return to the loading movement versus long-term immobilization)

Unstable ankle injuries are treated surgically through open fracture adjustment and internal anastomosis. For this purpose, the surgeon uses screws and plates dedicated to the ankles. In the case of ankle fractures with damage to the tibiofibular ligament, the anatomical adjustment of the arrow and fusion of the fibula with the tibia is performed using ligamentous screws or "endobutton" stabilization (repair - drainage of the said "ankle fork separation"). carried out up to a few days after the injury. Open fractures require the quickest possible adjustment of the fragments after prior thorough tissue cleaning. To reduce the risk of infection, external anastomosis is sometimes used.

Stable fractures can be treated surgically or conservatively. Conservative treatment of stable fractures is rather used in the elderly, inactive people and in people with chronic diseases that hinder the healing of soft tissues. The leg is covered with a plaster covering the ankle joint or, more rarely, a higher plaster covering the knee joint. During the healing period, "Walker" type orthoses are used, which allow for partial loading of the limb, when the doctor allows it. The main disadvantage of conservative treatment of ankle fractures is the difficulty in maintaining perfect fracture alignment until complete union is achieved. Therefore, the method of surgical treatment is more often chosen in young active people and athletes (regardless of the type of fracture).

Rehabilitation after an ankle fracture

The rehabilitation process should always be carried out in cooperation with the physiotherapist and the orthopedist who performs the surgery or conducts conservative treatment. It is important to jointly establish a physiotherapy plan and its specific goals and limitations - depending on the mechanism of the injury, the type of fracture and the type of anastomosis.

Rehabilitation exercises should start on the 2-3rd postoperative day and are designed to enable upright standing and safe walking. As a rule, the operated limb cannot be loaded for at least 6-8 weeks, and in some cases even for 10 weeks. During this period, the patient uses crutches, initially wearing a plaster shoe and then wearing a special Walker brace. Gradual load on the limbs can only be started after the orthopedic surgeon has informed about the bone union and healing of the tibiofibular ligament. The first limb loading may take the form of exercises using the so-called irradiation or transfer of arousal. The physiotherapist applies resistance to the upper limb or torso, inducing a specific support pattern for the lower limb. Thanks to the lying position with the foot against the wall or in a half-sitting position, the patient feels safer and more confident during the first attempts to load the operated ankle. It is also a good way to train proprioception, i.e. feeling the position of the ankle joint without eye control. Then the patient learns to properly load the foot on the ground while walking.

In the case of conservative treatment, after removing the plaster, especially important are exercises to stretch the calf triceps muscle, which after prolonged immobilization is contracted and disturbs the biomechanics of the lower limb.

The time it takes to regain full fitness varies - depending on the extent of the injury, it may take from 3 to 8 months. The patient's involvement in the rehabilitation process is of great importance in the recovery process. It should be borne in mind that some complex types of fractures may prevent the perfect reconstruction of the articular surfaces, which is related to a certain limitation of the joint function, despite the maximum effort put into the rehabilitation process.

Sources:
Gaździk TS. Złamania kostek goleni. Ortho & Trauma 3(3),2006: 25-34.
Benirschke S. Kramer P. Złamania kostek [w:] DiGiovanni C. Greisberg J. (Marczyński J. red.) Stopa i staw skokowo-goleniowy: Core Knowledge of Orthopaedics, Elsevier Urban&Partner, Wrocław 2010; s. 271-284.
Tarkin I. Cole P. Złamania typu pilon kości piszczelowej. [w:] DiGiovanni C. Greisberg J. (Marczyński J. red.) Stopa i staw skokowo-goleniowy: Core Knowledge of Orthopaedics, Elsevier Urban&Partner, Wrocław 2010; s. 285-301

Important information

Frequently asked questions about treating a broken ankle: