Ankle Fractures


Original Editor - Ewa Jaraczewska
Top Contributors - Ewa Jaraczewska

Introduction[edit | edit source]

Clinically Relevant Anatomy[edit | edit source]

The human ankle joint complex can be divided into a talocrural, a talocalcaneonavicular and a subtalar part.1 The talocrural (TC) joint is formed by three bones and a complex ligamentous apparatus. Tibia, fibula and talus are interconnected through collateral ligaments and the syndesmotic ligament complex.[1]

Ankle Joint[edit | edit source]

Ankle image.jpeg

Bones[edit | edit source]

The ankle is formed by three bones: the talus, tibia and fibula. The anatomical structure of the foot consists of the hindfoot, midfoot and forefoot. Each part of the foot is composed of several bones. The lower leg and foot constitute the ankle. The following bony elements of the ankle joint are part of this structure:[2]

The talocrural joint (TC or sometimes called a tibiotalar joint) is referred to as the ankle joint. The joint is framed laterally and medially by the lateral and the medial malleolus and from the top by the tibia and the talus. [3]Sagittal plane dorsiflexion and plantarflexion are the primary movements in this joint.

The hindfoot has a talus and calcaneus articulation called the subtalar joint (ST, also known as the talocalcaneal joint). Three facets of the talus and of the calcaneus are part of this joint. The main motions are inversion and eversion of the ankle and hindfoot.[3]

The talonavicular and calcaneocuboid joints are known as Chopart's joint (MT, midtarsal or transverse tarsal joint, or talocalcaneonavicular joint), which are located between the hindfoot and midfoot.This joint allows forefoot rotation. The navicular articulates with all three cuneiform bones distally. In addition to the navicular and cuneiform bones, the cuboid bone has a distal articulation with the base of the fourth and fifth metatarsal bones.[3]

Below is a summary of the ankle articulations:

Ankle joint.png

Figure 3-Ankle ligaments.PNG

Ligaments[edit | edit source]

The ligaments of the ankle consist of the medial ligaments (the deltoid ligament), the lateral ligaments, and the ligaments connecting the distal epiphyses of the tibia and fibula called the tibiofibular syndesmosis.[4]The medial collateral ligament (MCL) is divided into two layers: superficial and deep.[5]The lateral collateral ligament complex (LCL) is composed of three ligaments: the anterior talofibular, calcaneofibular, and posterior talofibular ligaments.[6]The tibiofibular syndesmosis articulation includes the anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and the interosseous tibiofibular ligament.[7]

You can read more about ankle ligaments here.

Muscles[edit | edit source]

The lower leg muscles are divided into four compartments: the superficial posterior compartment, the deep posterior compartment, the lateral compartment, and the anterior compartment. The primary plantar flexors of the ankle are located in the posterior compartment. Muscles of the lateral compartment are plantar flexing the ankle and everting the foot. Ankle dorsiflexion is performed by all the muscles within the anterior compartment.

More information on the muscles and fascia of the ankle can be found here.

Anatomy ankle and foot 5.jpg

Neural and Vascular[edit | edit source]

Neural[edit | edit source]

The Tibial nerve originates at L5, S1 and S2 levels together with the common peroneal (fibular ) nerve. It provides motor fibres to gastrocnemius, soleus, tibialis posterior, flexor digitorum longus, and flexor hallucis longus. These nerve sensory fibres occasionally supply the area typically innervated by the deep peroneal nerve.[8]

The common fibular nerve originates at nerve roots L4, S1, and S2 together with the tibialis nerve. Its superficial branch sends motor fibres to fibularis longus and brevis. The deep branch occasionally becomes the pure sensory nerve and it sends motor fibres to tibialis anterior, extensor digitorum longus, extensor hallucis longus, extensor digitorum brevis (rarely innervated by the tibial nerve), and the sensory fibres to lateral part of the ankle and foot regions, the skin between the first and second toes.[8]

The Sural nerve originates from the tibial nerve and cutaneous branches of the common fibular nerve. It is divided into the sural communication nerve and lateral sural cutaneous nerve. Its sensory fibres innervate the posterior aspect of the distal leg and the lateral aspect of the foot.[8]

Vascular[edit | edit source]

The following arteries supply the distal aspect of the lower leg:

  • Popliteal Artery: superficial posterior compartment including gastrocnemius, soleus and plantaris muscles.
  • Tibial Artery
    • Anterior tibial artery: proximal tibiofibular joint, knee joint, ankle joint, muscles and skin of the anterior compartment of the leg.
    • Posterior tibial artery: soleus muscle, popliteus, flexor hallucis longus, flexor digitorum longus and tibialis posterior.
  • Fibular artery: popliteus, soleus, tibialis posterior, and flexor hallucis longus muscles.
  • Sural Artery: gastrocnemius muscle, soleus muscle and plantaris muscle.


You can read more about ankle neural and vascular systems here.

Ankle fracture.jpg

Classifications of Fractures[edit | edit source]

Clinically relevant classification for the ankle fractures includes the following:[9]


Classification based on stability criteria was proposed by Michelson and colleagues.[10] According to Michelson et al., the following pathology defines the unstable ankle fracture:[11]

  • any ankle fracture-dislocation
  • any bimalleolar or tri-malleolar ankle fracture
  • any lateral malleolar fracture with significant talar shift on any plain radiograph view at any time.

The ankle fracture is considered stable when none of the above criteria is met.[12]

The AO/OTA classification system is mostly used to classify malleolar fractures, and is based on the severity and complexity of the injury:[13]

  • Type A: infrasyndesmotic fibular injury (with three subgroups)[13]
  • Type B:transsyndesmotic fibular fracture (with three subgroups)[13]
  • Type C: suprasyndesmotic injury (with three subgroups)[13]

You can learn more about AO/OTA classification here.

Clinical Presentation[edit | edit source]

Patients present to the emergency room with ankle fractures due to falls, inversion injuries, sports-related injuries, or minor trauma due to diabetes, peripheral neuropathy and other medical conditions. [14]The most common symptoms when an ankle fracture is suspected include:

  • Pain
  • Bruising
  • Swelling of the ankle
  • Inability to weight bear[14]

Diagnostic Procedures[edit | edit source]

You can read about ankle investigations and tests here.

Patient reported outcome measures in ankle instability. Red: inadequate or not assessed. Yellow: inconsistent or minor issues. Green: adequate. Adapted from Hansen CF, Obionu KC, Comins JD, Krogsgaard MR. The patient-reported outcome measures for ankle instability. An analysis of 17 existing questionnaires. Foot Ankle Surg. 2022 Apr;28(3):288-293

Outcome Measures[edit | edit source]

A wide variety of outcome measures are available to use in adults with ankle fractures: [15]

Management / Interventions[edit | edit source]

General considerations[edit | edit source]

In order to choose the most appropriate intervention after an ankle fracture, the physiotherapist must consider the following:

  • Presence of “variety” of protocols with lack of conclusive recommendations [20][21][22][23]
  • Two trends in the literature
    • Traditional protocol[24]includes incremental weight bearing after 6 weeks - 12 weeks full weight, based on the mechanism of injury, and other soft tissue involvement.
    • Early mobilisation protocol includes early weight bearing (before 6 weeks), early exercises, general conditioning, orthoses, and manual therapy.[25]
  • The OUTCOMES of traditional protocol include:[20]
    • Talo-crural and sub-talar joints stiffness [26]
    • Decreased strength[26]
    • Mid-thigh muscle atrophy at 28 days [26]
    • Gait pathology[27]
    • Decreased functional activity and quality of life at 6 months[28]
    • Patient-reported outcome measures do not correlate with clinical findings [29]
  • The OUTCOMES of early mobilisation protocol include:[30][31]
    • No more complications than traditional regime[32]
    • Early return to work than traditional regime[32]
    • Decreased risk of thromboembolism and osteoporosis[20]
    • Decreased risk of Complex Regional Pain Syndrome (CRPS)[20]
    • Improved general well-being and social re-interaction of patient[20]
    • Decreased socio-economic costs[20]

Early Mobilisation Protocol[edit | edit source]

Exercises in Early Phase

Early phase (3 – 6 weeks post-surgery)[20][edit | edit source]

  • Desensitisation of CRPS: brushing, mirror therapy
  • General conditioning in non-weight bearing (NWB) and partial weight bearing (PWB): arm ergometer, stationary cycling, Pilates on reformer, circuit training gym
  • Prepare for full weight bearing (FWB) gait at 6 weeks
Partial to Full Weight Bearing Phase

Full weight bearing: PWB - FWB (4 - 6 weeks post-surgery)[20][edit | edit source]

  • Functional rehabilitation:
    • cardio-vascular fitness (cycling)
    • strengthening exercises with less than 50% of body weight
    • proprioceptive exercises (Balance Error Scoring System(BESS) with crutches)
Full Weight Bearing Phase (6-8 weeks)

Full weight bearing (week 6-8 post surgery)[20][edit | edit source]

  • Gait (cycle to warm up, then walk)
  • Decline squats
  • Proprioceptive exercises: Tandem standing lunge with twists, perturbation exercises (pull at stable base)
Full Weight Bearing Phase (8-10 weeks)

Full weight bearing (week 8-10 post surgery)[20][edit | edit source]

Week 10 to Final Phase[20][edit | edit source]

  • Walking endurance with load (walking to work and back with a backpack)
  • Jumping and landing (indoor climbing wall)
  • Total time since accident – 14 weeks: hiking, post-traumatic stress therapy
  • Orthoses: hiking boots, inserts, compression sleeve for lower legs

Resources[edit | edit source]

References[edit | edit source]

  1. Pflüger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crönlein M. Current management of trimalleolar ankle fractures. EFORT Open Reviews. 2021 Aug 10;6(8):692-703.
  2. Brockett CL, Chapman GJ. Biomechanics of the ankle. Orthopaedics and trauma. 2016 Jun 1;30(3):232-8.
  3. 3.0 3.1 3.2 Ficke J, Byerly DW. Anatomy, Bony Pelvis and Lower Limb, Foot. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546698/
  4. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69.
  5. Milner CE, Soames RW. Anatomy of the collateral ligaments of the human ankle joint. Foot Ankle Int. 1998 Nov;19(11):757-60.
  6. Szaro P, Ghali Gataa K, Polaczek M. et al. The double fascicular variations of the anterior talofibular ligament and the calcaneofibular ligament correlate with interconnections between lateral ankle structures revealed on magnetic resonance imaging. Sci Rep 2020;10: 20801.
  7. Yammine K, Jalloul M, Assi C.Distal tibiofibular syndesmosis: A meta-analysis of cadaveric studies. Morphologie, 2021.
  8. 8.0 8.1 8.2 Yamashita M, Mezaki T, Yamamoto T. "All tibial foot" with sensory crossover innervation between the tibial and deep peroneal nerves. J Neurol Neurosurg Psychiatry. 1998 Nov;65(5):798-9.
  9. 9.0 9.1 Olczak J, Emilson F, Razavian A, Antonsson T, Andreas Stark A, Gordon M. Ankle fracture classification using deep learning: automating detailed AO Foundation/Orthopedic Trauma Association (AO/OTA) 2018 malleolar fracture identification reaches a high degree of correct classification. Acta Orthopaedica, 2021; 92(1): 102-108,
  10. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007 May;21(5):307-15.
  11. Fonseca LLD, Nunes IG, Nogueira RR, Martins GEV, Mesencio AC, Kobata SI. Reproducibility of the Lauge-Hansen, Danis-Weber, and AO classifications for ankle fractures. Rev Bras Ortop. 2017 Dec 6;53(1):101-106
  12. Lambert LA, Falconer L, Mason L. Ankle stability in ankle fracture. J Clin Orthop Trauma. 2020 May-Jun;11(3):375-379.
  13. 13.0 13.1 13.2 13.3 Feger J. AO/OTA classification of malleolar fractures. Reference article. Available from https://radiopaedia.org/articles/aoota-classification-of-malleolar-fractures [last access 29.06.2022]
  14. 14.0 14.1 Seewoonarain S, Prempeh M, Shakokani M, Magan A. Ankle fractures. Journal of Arthritis. 2016:1-4.
  15. 15.0 15.1 15.2 15.3 15.4 15.5 McKeown R, Rabiu AR, Ellard DR, Kearney RS. Primary outcome measures used in interventional trials for ankle fractures: a systematic review. BMC Musculoskelet Disord 2019; 20 (388).
  16. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Archives of orthopaedic and traumatic surgery. 1984 Sep;103(3):190-4.
  17. 17.0 17.1 17.2 17.3 Hansen CF, Obionu KC, Comins JD, Krogsgaard MR. Patient reported outcome measures for ankle instability. An analysis of 17 existing questionnaires. Foot Ankle Surg. 2022 Apr;28(3):288-293
  18. Dawson J, Boller I, Doll H, Lavis G, Sharp R, Cooke P, Jenkinson C. The MOXFQ patient-reported questionnaire: assessment of data quality, reliability and validity in relation to foot and ankle surgery. The Foot. 2011 Jun 1;21(2):92-102.
  19. Nguyen MQ, Dalen I, Iversen MM, Harboe K, Paulsen A. Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties. Qual Life Res. 2022 Jun 18.
  20. 20.00 20.01 20.02 20.03 20.04 20.05 20.06 20.07 20.08 20.09 20.10 Simpson H. Ankle Fractures Course. Physiopedia. 2022
  21. Lin CWC, Donkers NAJ, Refshauge KM, Beckenkamp PR, Khera K, Moseley AM. Rehabilitation for ankle fractures in adults. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD005595.
  22. Pfeifer CG, Grechenig S, Frankewycz B, Ernstberger A, Nerlich M, Krutsch W. Analysis of 213 currently used rehabilitation protocols in foot and ankle fractures. Injury. 2015 Oct;46 Suppl 4:S51-7.
  23. Swart E, Bezhani H, Greisberg J, Vosseller JT. How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members. Injury. 2015;46(6):1127-30
  24. Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Dtsch Arztebl Int. 2014 May 23;111(21):377-88.
  25. Albin SR, Koppenhaver SL, Marcus R, Dibble L, Cornwall M, Fritz JM. Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2019 May;49(5):310-319
  26. 26.0 26.1 26.2 Nilsson G, Nyberg P, Ekdahl C, Eneroth M. Performance after surgical treatment of patients with ankle fractures--14-month follow-up. Physiother Res Int. 2003;8(2):69-82.
  27. Suciu O, Onofrei RR, Totorean AD, Suciu SC, Amaricai EC. Gait analysis and functional outcomes after twelve-week rehabilitation in patients with surgically treated ankle fractures. Gait Posture. 2016 Sep;49:184-189.
  28. Beckenkamp PR, Lin CW, Engelen L, Moseley AM. Reduced Physical Activity in People Following Ankle Fractures: A Longitudinal Study. J Orthop Sports Phys Ther. 2016 Apr;46(4):235-42
  29. Ng R, Broughton N, Williams C. Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems. J Foot Ankle Surg. 2018 Jan-Feb;57(1):149-154.
  30. Jansen H, Jordan M, Frey S, Hölscher-Doht S, Meffert R, Heintel T. Active controlled motion in early rehabilitation improves outcome after ankle fractures: a randomized controlled trial. Clin Rehabil. 2018 Mar;32(3):312-318.
  31. Dehghan N, McKee MD, Jenkinson RJ, Schemitsch EH, Stas V, Nauth A, Hall JA, Stephen DJ, Kreder HJ. Early Weightbearing and Range of Motion Versus Non-Weightbearing and Immobilization After Open Reduction and Internal Fixation of Unstable Ankle Fractures: A Randomized Controlled Trial. J Orthop Trauma. 2016 Jul;30(7):345-52
  32. 32.0 32.1 Smeeing DP, Houwert RM, Briet JP, Kelder JC, Segers MJ, Verleisdonk EJ, Leenen LP, Hietbrink F. Weight-bearing and mobilization in the postoperative care of ankle fractures: a systematic review and meta-analysis of randomized controlled trials and cohort studies. PLoS One. 2015 Feb 19;10(2):e0118320.