Ankle and Foot Fractures

Definition/Description

An ankle fracture is a fracture in a bone that shapes the ankle. This can be the end of the fibula (malleolus lateralis), the end of the tibia (malleolus medialis) or both (bimalleolar fracture). They usually result from an external rotation injury to the ankle.

Ankle fractures are classified by the AO classification. More information about this classification:

http://www.physio-pedia.com/index.php5?title=AO_classification

Be aware that many people mistake an ankle fracture for an ankle sprain. This injuries are quite different and need an accurate and early diagnosis.

Clinically Relevant Anatomy

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Epidemiology /Etiology

There are different causes for an ankle fracture:
- A big force that works into the bone. For example a kick or a smack during sport activities or a car accident.
- A little piece of the bone tears off when there is pulled at a ligament. For example when you stumble.
- Twisting or rotating your ankle
- Rolled your ankle

Characteristics/Clinical Presentation

- Difficulties or even inability to walk or load the ankle. (it is possible to walk with less severe breaks, so never rely on walking as a test of whether a bone has been fractured.
- Pain
- Swelling, along the length of the leg or more localized
- Blisters (over the fracture site).
- Bruising (soon after the injury).
- Difference in appearance.
When an ankle has been broken, there is not only structural damage to the skeletal structure, but also to the ligament tissue (deltoid ligament and the anterior and posterior tibiofibular ligaments) and possibly nervous and musculoskeletal tissue around the ankle complex.. This can result in impaired balance capacity, reduced joint position sense, slowed nerve conduction, velocity, impaired cutaneous sensation and decreased dorsal extension range of motion. [2, Level of evidence: B]

Differential Diagnosis

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Diagnostic Procedures

To evaluate the ankle in the acute fase, we use the ‘Ottawa ankle rules’. Ottawa_Ankle_Rules

Examination

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Medical Management

Most patients with a malleolus fracture require 6 weeks of immobilization. Patients with an initially non-displaced fracture or who were treated surgically will generally require 4 weeks of non-weight bearing in a short-leg cast or removable walking boot, followed by 2 weeks in a walking cast or boot. The removable boot will allow for earlier range-of-motion exercises.
Surgery is needed for many types of ankle fractures. While not always necessary, surgery for ankle fractures is not uncommon. The need for surgery depends on the appearance of the ankle joint on X-ray and the type of ankle fracture.
Adequate reduction with congruency of the joint has been reported as one of the most important indications of a good end result. Inadequate reduction may lead to osteoarthritis.

Physical Therapy Management

After 6 weeks of immobilization, the ankle can be fully loaded. There is no standardized rehabilitation program after cast removal. Each program is individually. [2, Level of evidence: B]

Physiotherapists are often involved in the rehabilitation, which starts quickly (1 week) after the period of immobilization. Most people experience pain, swelling, stiffness, muscle atrophy and decreased muscle torque[1][4, Level of evidence: B], impaired ankle mobility, impaired balance capacity and increased ankle circumference[2, Level of evidence: B] at the ankle after cast removal. Consequently, patients complain of limitation in activities involving the lower limb, such as stair climbing, walking and reduced participation in work and recreation. It has been found that patients with unimalleolar fractures report less activity limitation than those with bimalleolar or trimalleolar fractures. [7]

Passive joint mobilization is commonly used to work on the problems of pain and joint stiffness, in order to allow an earlier return to activities. For this technique, the physiotherapist manually glides the articular surfaces of a joint to produce oscillatory movements. It has been proven that manual therapy, such as joint mobilization, produces analgesic effects. It also increases elasticity of joint structures through interactions at the local, central nervous system and psychological levels. [4, Level of evidence: B]

There is evidence that, after a surgical treatment for an ankle fracture, a training program, started within one week after cast removal and continued for 12 weeks (with 2 appointments per week), shows superior results compared to usual care, regarding patient scored function and muscle strength in the plantar flexors and dorsiflexors of patients under the age of 40. The patients had to do home exercises daily, prescribed by the physiotherapist, appropriate to the functional status at the time. Functional goals are loaded ankle dorsiflexion, plantairflexion, on-leg-stance, rising on toes, rising on heels, normalized walking pattern when walking on even ground, on stairs and at comfortable speed. [3, Level of evidence: A2]

 

When the cast is removed, many patients have a plantarflexion contracture (http://www.physio-pedia.com/index.php5?title=Plantarflexion_contracture). This contracture is not caused directly by fracture but develops as an adaptive response to immobilization. The addition of a program of passive stretches has no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization. [6, Level of evidence: B]

Resources

http://orthopedics.about.com/od/footanklefractures/Information_About_Foot_Ankle_Fractures.htm
http://www.foothealthfacts.org/footankleinfo/ankle-fracture.htm
http://www.invaliditeit.be/enkelbreuk.html
http://www.associatie-orthopedie-lier.be/Generic/servlet/Main.html?p_pageid=37245
http://www.dokterdokter.nl/medisch/folder/view/id/1582/gebroken-enkel

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References 

[1] Nilsson G, Jonsson K, Ekdahl CH, Eneroth M. Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Musculoskeletal Disorders 2007;8:127

[2] Nilsson G, Nyberg P, Ekdahl CH, Eneroth M. Performance after surgical treatment of patients with ankle fractures – 14-month follow-up. Physiotherapy Research International 2003, 8(2) 69-82 

[3] Nilsson G, Jonsson K, Ekdahl CH, Eneroth M. Effects of a training program after surgically treated ankle fracture : a prospective randomised controlled trial. BMC Musculoskeletal Disorders 2009;10:118

[4] Lin C CH, Moseley AM, Refshauge KM, Haas M, Herbert RD. Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial. BMC Musculoskeletal Disorders 2006;7:46 

[5] Nilsson G, Ageberg E, Ekdahl CH, Eneroth M. Balance in single-limb stance after surgically treated ankle fractures: a 14-month follow-up. BMC Musculoskeletal Disorders 2006;7 :35

[6] Moseley AM, Herbert RD, Nightingale EJ, Taylor DA, Evans TM, Robertson GJ, Gupta SK, Penn J. Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture : a randomized controlled trial. Arch Phys Med Rehabil 2005;86 :1118-26

[7] Lin CC, Moseley AM, Herbert RD, Refshauge KM. Pain and dorsiflexion range of motion predict short-and medium-term activity limitation in people receiving physiotherapy intervention after ankle fracture: an observational study. Australian Journal of Physiotherapy 2009, 55;31-37

[8] Thordarson DB, MD. Detecting and treating common foot and ankle fractures: Part 1: the ankle and hindfoot. The physician and sportsmedicine 1996;24:9