Ankle Fractures
​Overview
An ankle fracture is a break in one or more of the bones that make up the ankle joint:
  • Tibia (shin bone)
  • Fibula (outer lower-leg bone)
  • Talus (ankle bone of the foot)
Ankle fractures are common and can range from small, stable cracks to complex breaks that disrupt joint alignment. They may involve only one side of the ankle (unimalleolar), both sides (bimalleolar), or both sides plus the tibia’s back edge (trimalleolar). Because the ankle is a weight-bearing joint, proper alignment and healing are critical to restore function and prevent arthritis.


Etiology (Causes & Risk Factors)
Ankle fractures occur when forces exceed the strength of the bone and supporting ligaments. Frequent mechanisms include:
  • Twisting or rolling injuries (sports, slipping on ice, uneven surfaces)
  • Falls from a height or stepping awkwardly off a curb
  • High-energy trauma such as motor vehicle collisions or crush injuries
  • Stress fractures from repetitive overuse (less common)
Risk factors that increase fracture likelihood:
  • Osteoporosis or low bone mineral density
  • Smoking, which impairs bone healing
  • Diabetes or peripheral neuropathy (altered sensation and healing)
  • Previous ankle injuries or chronic instability


Symptoms
  • Sudden severe pain at the ankle
  • Swelling and bruising
  • Difficulty or inability to bear weight
  • Visible deformity or misalignment
  • In open fractures: broken skin, bleeding, or exposed bone (medical emergency)


Diagnosis
A clinician will:
  • Take a history of the injury and examine for deformity, tenderness, and neurovascular status.
  • Order imaging:
    • X-rays (AP, lateral, mortise views) are standard.
    • CT scans for complex or intra-articular fractures.
    • MRI if ligament, cartilage, or occult injury is suspected.
Classification systems such as Lauge-Hansen (mechanism-based) and Weber/Danis-Weber (fibula fracture level) help guide treatment and prognosis.


Treatment Options
Management depends on fracture stability, alignment, and patient factors.
Non-Operative (Conservative)
  • Appropriate for stable, non-displaced fractures with intact joint alignment.
  • Immobilization with a cast, splint, or walking boot.
  • Elevation, ice, and non-weight bearing initially.
  • Gradual transition to protected weight bearing after 4–6 weeks.
Operative (Surgical)
  • Recommended for unstable or displaced fractures, open fractures, or fractures with dislocated joints.
  • Open Reduction and Internal Fixation (ORIF) is the most common procedure: bones are realigned and held with plates, screws, or intramedullary devices.
  • External fixation may be used temporarily if soft-tissue swelling prevents immediate ORIF.
Post-operative care includes pain control, physical therapy, and gradual return to full weight bearing over 6–12 weeks, depending on bone healing and soft tissue recovery【


Expectations & Recovery
  • Bone healing: typically 6–8 weeks.
  • Physical therapy: begins once adequate healing is confirmed to restore motion, strength, and balance.
  • Return to normal activity: often 3–4 months for daily tasks; 4–6 months or more for sports.
  • Long-term considerations: Some patients may develop residual stiffness, swelling, or post-traumatic ankle arthritis, particularly after severe or joint-involving fracturesPrompt diagnosis and appropriate treatment greatly reduce the risk of chronic pain and disability.


References
  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–7. PubMed
  2. Michelson JD. Ankle fractures resulting from rotational injuries. J Am Acad Orthop Surg. 2003;11(6):403–12. PubMed
  3. Sanders DW, et al. Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial. J Orthop Trauma. 2012;26(3):129–34. PubMed
  4. Bugler KE, et al. Operative versus nonoperative management of unstable lateral malleolar fractures: a multicenter randomized clinical trial. J Bone Joint Surg Am. 2012;94(6):523–31. PubMed
  5. Lambers K, et al. Posttraumatic ankle arthritis: a systematic review. Foot Ankle Surg. 2015;21(1):11–9. PubMed