Ankle Fractures

Question 1

Ankle fractures are common lower limb fractures often occurring due to …-energy torsional trauma.

Answer 1

Ankle fractures are common lower limb fractures often occurring due to low-energy torsional trauma.

Question 2

Do ankle fractures affect men or women more?

Answer 2

They affect women more than men, most commonly those aged 30-60.

Question 3

The ankle is a … joint, formed by the malleoli & talus.

Answer 3

The ankle is a hinge joint, formed by the malleoli & talus.

Question 4

The ankle is a hinge joint, formed by the … & ….

Answer 4

The ankle is a hinge joint, formed by the malleoli & talus.

Question 5

The ankle is a hinge joint, formed by the malleoli & talus. It is reinforced medially and laterally by … ligaments and stabilised by the ….

Answer 5

The ankle is a hinge joint, formed by the malleoli & talus. It is reinforced medially and laterally by collateral ligaments and stabilised by the syndesmosis.

Question 6

Deltoid ligament - also known as the …

Answer 6

Also known as the medial collateral ligament, it is a strong, broad, triangular ligament. It is composed of two layers: superficial and deep.

Question 7

The … collateral ligament comprises three ligaments, the anterior talofibular ligament (ATFL), calcaneofibular ligament & posterior talofibular ligaments (PTFL)

Answer 7

The lateral collateral ligament comprises three ligaments, the anterior talofibular ligament (ATFL), calcaneofibular ligament & posterior talofibular ligaments (PTFL)

Question 8

The … syndesmosis complex stabilises the ankle joint.

Answer 8

The tibiofibular syndesmosis complex stabilises the ankle joint. Composed of several ligaments and the interosseous membrane, it prevents the tibia & fibula from splaying during weight-bearing.

Question 9

There are a number of classifications used for ankle fractures, the … classification is the most important to be aware of as a student.

Answer 9

There are a number of classifications used for ankle fractures, the Weber classification is the most important to be aware of as a student.

Question 10

Weber classification - what is this?

Answer 10

Attempts to differentiate rotational ankle fractures in relation to overall stability. Based on the level of the fibular fracture in relation to the syndesmosis (typically described with regards to the tibial plafond - essentially the ‘base’ of the tibia).

Question 11

A - Fracture … the level of the syndesmosis; typically from an inversion injury of the ankle.

Answer 11

A - Fracture below the level of the syndesmosis; typically from an inversion injury of the ankle.

Question 12

A - Fracture below the level of the syndesmosis; typically from an … injury of the ankle.

Answer 12

A - Fracture below the level of the syndesmosis; typically from an inversion injury of the ankle.

Question 13

B - Fracture begins at the level of the syndesmosis and extends proximally in an oblique fashion. When accompanied by a fracture of the medial malleolus or rupture of the deltoid ligament, the ankle is considered unstable. Typically from an … injury of the ankle.

Answer 13

B - Fracture begins at the level of the syndesmosis and extends proximally in an oblique fashion. When accompanied by a fracture of the medial malleolus or rupture of the deltoid ligament, the ankle is considered unstable. Typically from an eversion injury of the ankle.

Question 14

C - Fractures … the syndesmosis, generally associated with syndesmotic injury. May be associated with an avulsion fracture of the medial malleolus or rupture of the deltoid ligament. Always unstable, requiring …c

Answer 14

C - Fractures above the syndesmosis, generally associated with syndesmotic injury. May be associated with an avulsion fracture of the medial malleolus or rupture of the deltoid ligament. Always unstable, requiring fixation.

Question 15

A Maisonneuve fracture describes a fracture of the … fibula combined with an … ankle injury.

Answer 15

A Maisonneuve fracture describes a fracture of the proximal fibula combined with an unstable ankle injury.

Question 16

Sometimes considered a high Weber C, should not be missed! On occasion the energy from an ankle injury will pass through the ankle and syndesmosis and exit at the proximal fibula. This implies the energy has ruptured the syndesmosis resulting in an unstable ankle. - what fracture is this?

Answer 16

Maisonneuve fracture - Sometimes considered a high Weber C, should not be missed! On occasion the energy from an ankle injury will pass through the ankle and syndesmosis and exit at the proximal fibula. This implies the energy has ruptured the syndesmosis resulting in an unstable ankle.

Question 17

Symptoms and Signs of ankle fractures

Answer 17

Symptoms

Pain
Inability to weight bear
Signs

Bony tenderness
Swelling
Deformity

Question 18

The Ottawa ankle rules help differentiate ankle injuries that require … assessment from those that do not.

Answer 18

The Ottawa ankle rules help differentiate ankle injuries that require radiographic assessment from those that do not.

Question 19

Ottawa ankle rules

Answer 19

They state that an ankle radiograph series is only required if there is pain in the malleolar zone (highlighted turquoise in below image) and one or more of the following is found:

Boney tenderness at the posterior edge or tip of the lateral malleolus OR
Boney tenderness at the posterior edge or tip of the medial malleolus OR
Inability to weight bear immediately and in the A+E department for four steps

Question 20

Bedside test for ankle fractures

Answer 20

Observations
Urine dip (if indicated on suspicion of infection)
Pregnancy test
ECG (if needed pre-op, or possible cardiac cause of fall)

Question 21

Blood tests in ankle fractures

Answer 21

FBC
U&Es
CRP
Clotting screen

Question 22

Imaging - ankle fractures

Answer 22

XR ankle: An ankle series consisting of a AP, mortise and true lateral. The mortise view allows us to assess for talar shift. Talar shift refers to the widening of medial clear space and is indicative of an unstable injury with damage to the syndesmosis. It may not be evident on non-weight bearing films.
XR fibula/tibia: Indicated when there is suspicion of Maisonneuve injury.
CT ankle: Helps better define fracture pattern, should be obtained in complex ankle fractures, particularly those involving the posterior malleolus.

Question 23

Management of ankle fractures may involve … (3)

Answer 23

Management of ankle fractures may involve a walking boot, cast or surgical fixation.

Question 24

Weber A fractures - management

Answer 24

Weber A fractures are generally stable. Surgical management is rarely indicated and they can be discharged from A&E in a walking boot with analgesia. Elevation and iceing at home can help with pain and swelling.

All patients should be followed up in fracture clinic for re-assessment and to confirm a healing injury. Those unable to mobilise safely with a walking boot may require admission for PT/OT assessment.

Question 25

Unstable injuries - ankle fracture management

Answer 25

Analgesia - Ankle fractures are painful injuries and analgesia should be given as soon as is possible and safe. Take into account allergies, age, renal function, weight, current medications and co-morbidities.

Reduce and cast - In those with clinically deformed ankles - reduction and splinting should be performed urgently, though generally radiographs should be taken prior unless there will be delay. Reductions of dislocated ankles should be completed in Resus with appropriate analgesia and sedation (e.g. Ketamine) and airway cover. If no reduction is required or once reduction is complete the patient should be placed in a below knee backslab.

Re-assess - Imaging should be repeated to confirm reduction and positioning. After any reduction or casting repeat a neurovascular assessment.

Elevate - All patients should be encouraged to keep the affected limb elevated at rest.

Referral - Patients should be referred to orthopaedics for review and discussion at the trauma meeting. Generally they should be kept NBM until review.

Question 26

Many Weber B and most Weber C will benefit from surgical fixation. This decision is made by the orthopaedic team taking into account the fracture pattern, patient co-morbidities and wishes. Rarely … may be needed in the presence of gross swelling.

Answer 26

Many Weber B and most Weber C will benefit from surgical fixation. This decision is made by the orthopaedic team taking into account the fracture pattern, patient co-morbidities and wishes. Rarely external fixation may be needed in the presence of gross swelling.

Question 27

What is important to consider in ankle fractures regarding prophylaxis treatment?

Answer 27

There is an increased risk of VTE in lower limb fractures - particularly if the limb is immobilised in a cast.

Follow local guidelines and prescribe VTE prophylaxis where appropriate. Patients should also be informed of the risk, signs and symptoms to be aware of and to seek medical attention immediately if they occur (ideally also given a patient information leaflet).

Question 28

In patients who are elderly or co-morbid (e.g. diabetes mellitus, peripheral neuropathy) … … … should be considered for definitive management of ankle fracture

Answer 28

In patients who are elderly or co-morbid (e.g. diabetes mellitus, peripheral neuropathy) closed contact casting (CCC) should be considered for definitive management. Complications associated with surgery (e.g. infection) are eliminated though there appears to be a higher risk of mal-union with CCC.