How an ankle breaks and what types of fractures there are
The foot turns inward or outward, while the lower leg, by inertia, continues to move and turns around. The ligaments are pulled and either tear or tear off a piece of bone, and the ankle itself breaks under the force of the lever. The direction and strength of this movement determines what exactly will break and how stable the damage will be. Hence, there are fundamentally different treatment scenarios for an outwardly similar injury.
The key word here is stability. The ankle is considered stable when the talus is securely held in the fork and cannot move. If only the outer malleolus is broken and the internal structures are intact, the fork retains its shape and the fracture can be treated without surgery. If, along with the outer ankle, the inner ankle or the deltoid ligament that holds it is damaged, the fork opens, the talus gets free - and no plaster cast on the outside will correct this. Therefore, the doctor always feels the inside of the joint, even if the person complains only about the outside.
- Isolated fracture of the lateral malleolus is the most common option, often non-displaced and stable
- Fracture of the medial malleolus - rarely isolated, usually as part of a more severe injury
- Bimalleolar fracture - both ankles are broken, the joint becomes unstable
- Trimalleolar fracture - a fracture of the posterior edge of the tibia is added, the most severe option
- Fracture involving damage to the tibiofibular joint, which holds the bones of the lower leg together
- Fracture with subluxation or dislocation of the foot - requires urgent reduction
Fracture or sprain: how to distinguish
It is impossible to completely distinguish between these conditions without an image, but traumatologists around the world use a simple set of signs - the Ottawa Rules. They do not make a diagnosis, but answer one question: is an x-ray necessary? The point is not to miss a fracture, but also not to unnecessarily irradiate everyone who twisted their leg.
- Pain when pressing on the posterior edge or apex of the lateral malleolus
- Pain when pressing on the posterior edge or tip of the inner malleolus
- Inability to take four steps immediately after injury and in the doctor's office
- Soreness at the base of the fifth metatarsal - on the outer edge of the foot
- Soreness in the area of the navicular bone - on the inner edge of the arch of the foot
If there is at least one of these signs, an x-ray is needed. Please note: being able to step on your feet is only one item out of five on this list, and not the clincher. The instantaneous huge swelling, bruise spreading to the foot and toes, deformation and crunching at the time of injury also tip the scales towards a fracture, but only a photograph gives the final answer.
Survey
- Осмотр с обязательной пальпацией обеих лодыжек, всей малоберцовой кости до колена, основания пятой плюсневой кости и ахиллова сухожилия.
- Проверка кровоснабжения и чувствительности стопы, состояния кожи над отломками.
- Рентген голеностопного сустава в трёх проекциях: прямой, боковой и специальной косой, на которой видна вилка сустава и ширина суставных щелей.
- КТ — при трёхлодыжечных, оскольчатых и внутрисуставных переломах, а также при планировании операции: она показывает размер заднего отломка и точное расположение линий перелома.
- МРТ — по показаниям, если подозревают разрыв связок, повреждение хряща таранной кости или если боль сохраняется, а перелома на снимках нет.
- Рентген с нагрузкой или сравнительные снимки — когда нужно оценить скрытую нестабильность межберцового соединения.
In the picture, the doctor looks not only at the fracture line. Equally important are the width of the joint space between the inner malleolus and the talus, the symmetry of the gaps around the talus and the amount of overlap of the tibia bones above the joint. A widening of the gap on the inside means that the deltoid ligament is torn, even if the inner malleolus itself is intact - and such a fracture of the outer malleolus can no longer be considered stable. It is these millimeters that differentiate a fracture that can be treated with a bandage from a fracture that requires surgery, even though at first glance both look the same.
Treatment without surgery
Stable fractures are treated conservatively: an isolated fracture of the lateral malleolus without displacement, in which the fork of the joint is not widened and the foot is positioned correctly. This is a fairly large proportion of all ankle fractures and the outcome is usually excellent. There is only one condition - regular monitoring, because a fracture that looks stable on the first day sometimes manifests itself differently after a week.
It is worth mentioning separately about modern rigid orthoses. They are more convenient than a cast, they can be removed for hygiene and exercise, and for stable fractures the results are no worse. But they have a downside: a removable bandage requires discipline. If a person takes off the orthosis “for a minute” and walks around the apartment without it, the fracture moves in exactly the same way as without any fixation. Therefore, the doctor decides whether to use a cast or an orthosis not only based on the type of fracture, but also taking into account how willing the patient is to comply with the regimen.
- Иммобилизация гипсовой повязкой или жёстким ортезом от кончиков пальцев до верхней трети голени.
- Контрольный рентген через 7–10 дней — проверка, не появилось ли смещение после спадения отёка.
- Средний срок фиксации — около 6 недель, точный срок определяет врач по снимкам.
- Режим нагрузки назначает врач: при стабильном переломе часто разрешают дозированную опору в ортезе, при нестабильном — ходьба на костылях без нагрузки.
- Возвышенное положение ноги и работа мышцами голени с первых дней — профилактика отёка и тромбозов.
- После снятия повязки — постепенное восстановление объёма движений и опоры.
When and how to operate
The operation is performed when the joint is unstable or its anatomy is disturbed. The surgeon’s task is not just to connect the bone, but to restore the ankle joint with millimeter precision: this determines whether arthrosis will develop in ten to fifteen years. The outer ankle is usually fixed with a plate with screws, the inner one with screws or a tightening wire loop; if the tibiofibular joint is ruptured, a separate fixing screw or flexible fixation is installed.
- Displacement of fragments that is not corrected or held closed
- Bimalleolar and trimalleolar fracture
- Expansion of the joint fork and damage to the tibiofibular joint
- Subluxation or dislocation of the foot
- Large posterior fragment of the tibia, involving a significant part of the articular surface
- Open fracture - emergency surgery
- Secondary displacement identified on the control image
In case of severe swelling, surgery is sometimes postponed for several days: operating through tense, swollen skin is dangerous due to the risk of suppuration and marginal necrosis of the wound. During this period, the leg is fixed temporarily and kept elevated, and intervention is performed when the symptom of skin wrinkling appears. This is not a waste of time, but part of the tactics. Metal structures are not always removed: usually this is discussed after a year and only if the plate interferes or bothers.
Recovery and why swelling lasts so long
The bone heals in about 6–8 weeks, but the function of the ankle takes longer to return - on average from three months to six months, with severe fractures up to a year. The most common complaint at this stage is swelling, which by the evening turns the leg into something unlike a healthy one. This is not a complication: lymphatic drainage in the lower leg after injury and surgery is restored slowly, and moderate swelling at the end of the day can persist for 3–6 months. It improves with elevated positions, compression stockings and, most importantly, a gradual return to normal walking.
The second most common complaint is lameness, which persists even when the pain is gone. The reason is usually not the bone, but that weeks without exercise have shortened the calf tendon and weakened the muscles of the lower leg. The foot stops fully bending upward, and the person compensates for this by turning the foot outward and shortening the step. Such a gait is fixed quickly, and then it is difficult to relearn it, so stretching the calf muscles and consciously working on an even step are included in the recovery program no later than strength exercises.
- Опору на ногу разрешает врач по контрольным снимкам, обычно постепенно — сначала часть веса, затем полная.
- Восстановление подвижности: сгибание и разгибание стопы, затем повороты, затем растяжение икроножных мышц.
- Тренировка баланса на одной ноге — обязательный этап, без него сохраняется чувство неуверенности и риск повторной травмы.
- Силовые упражнения на мышцы голени и стопы, ходьба в правильном темпе без прихрамывания.
- Возвращение к офисной работе — обычно через 6–10 недель, к физическому труду и спорту — от 4 до 6 месяцев.
- Длительные авиаперелёты в первые недели после операции обсуждают с врачом из-за риска тромбозов и усиления отёка.