Let’s meet the Ankle Joint:
The ankle joint plays a very important role in gait and propelling the body forward when it flexes downward and pushes off the ground. A significant amount of force and pressure are imparted upon this joint with each step. The ankle joint has a complex construct that takes on these forces while having most of its motion in a flexion direction while having rigidity in and side-to-side and rotation motion. It has a mortise type anatomy that makes it more complex than the hip or knee joints. The bones that make up the ankle joint are: the Talus (ankle bone), the Lateral Malleolus of the Fibula (outer leg bone), the Tibial Plafond (leg bone), and the Medial Malleolus of the Tibia (inner leg bone). The normal ankle joint should be able to have a total range of motion of about 70 degrees (20 upward flexion and 50 downward flexion) for normal function. The ankle joint does not tilt inward and outward. That is the job of the joint below the ankle called the subtalar joint.
What is an Ankle Fracture?
A break in the tibia bone or fibula bone or the talus near around the ankle joint is considered an ankle fracture. There are many types of ankle fractures that are dependent on the severity, location, and number of bones involved.
The bones can break in a straight line across, or in a twisted and complicated line. The fracture can involve the joint and the cartilage making it more severe. There can be a break in 1 or 2 or 3 bones at a time. The tibia could break in multiple areas. The severity of the fracture is usually based on the severity of the injury.
In some cases, there can be a sprain or tear of the ligament that spans between the 2 leg bones (tibiofibular, syndesmotic ligament) separating the 2 bones and widening the ankle joint. This injury will further complicate the fracture.
Types of Ankle Fractures:
Lateral Malleolus Fracture
- A lateral malleolus fracture is a fracture of the fibula.
- There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.
Medial Malleolus Fracture
- A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures can occur at different levels of the medial malleolus.
- Medial malleolar fractures often occur with a fracture of the fibula (lateral malleolus), a fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle ligaments.
Posterior Malleolus Fracture
- A posterior malleolus fracture is a fracture of the back of the tibia at the level of the ankle joint.
- In most cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken. This is because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.
- “Bi” means two. “Bimalleolar” means that two of the three parts or malleoli of the ankle are broken. (Malleoli is plural for malleolus.)
- In most cases of bimalleolar fracture, the lateral malleolus and the medial malleolus are broken and the ankle is not stable.
- “Tri” means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.
- The syndesmosis joint is located between the tibia and fibula, and is held together by ligaments. A syndesmotic injury may be just to the ligament — this is also known as high ankle sprain. Depending on how unstable the ankle is, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.
What are the symptoms of an Ankle Fracture?
Common symptoms of a broken ankle include:
- Immediate and severe pain
- Tender to touch
- Cannot put any weight on the injured foot
- Deformity (“out of place”), particularly if the ankle joint is dislocated as well
When excessive force is applied to the ankle’s soft tissue structures and bones, the patient may hear or feel a “pop” as the ligaments tear and the bone or bones break. The first signs are a shooting and searing pain on the outer or inner side of the ankle. There will be some degree of immediate swelling, sometimes the size of a tennis ball. There can be significant bruising of the skin around the ankle, heel, and even the toes. Some patients will not be able to place any pressure on the ankle. It is important to note that the patient may still be able to walk even if there is a fracture of the bone. In severe injuries, there can be a dislocation of the foot leading to the foot being in a deformed position.
What Causes an Ankle Fracture?
An ankle fracture is usually caused by a significant trauma. Patients with poor bone quality (osteoporosis), high arches (pes cavus), diabetic neuropathy, ankle instability, are at higher risk for an ankle fracture. Participating in high impact sports and those with significant lateral movements, especially without experience or a proper warm up can increase the chances of an ankle fracture.
Common causes of a broken ankle include:
- Twisting or rotating your ankle
- Rolling your ankle
- Tripping or falling
- Impact during a car accident
Ankle twists occur when the ankle twists, rolls, or turns beyond its normal motions, and a significant force is transmitted upon landing. The ankle can twist if the foot is planted unevenly on a surface, beyond the normal force of stepping. This causes the ligaments to stretch beyond their normal range while in the abnormal position.
If there is a severe in-turning or out-turning of the foot relative to the ankle, the forces cause the ligaments to stretch beyond their normal length. If the force is too strong, and the ankle bones hit one another, they can splinter and fracture.
How is an Ankle Fracture Diagnosed?
Diagnosis is achieved by the clinical examination and x-rays of the patient. Dr. Soomekh will listen to the patient’s complaints, symptoms, and goals. The examination involves a hands-on analysis of the patient’s ankle and its stability. There will be an evaluation of the quality and strength of the ankle ligaments and tendons that cross the ankle, and the bones and joints of the ankle. Digital radiographs (x-rays) of the ankle will be obtained in the office and reviewed with the patient to evaluate the extent of the fractures or dislocations. The positions of the bones and joints evaluated on the x-rays help to determine the severity of the deformity and any associated problems. Depending on the severity of the fracture, an in office CT scan may may needed to evaluate the nuances of the fracture in 3 dimensions.
How to Prevent an Ankle Fracture:
The best way to prevent an ankle fracture is to maintain good strength, muscle balance and flexibility.
- Warm-up before doing exercises and vigorous activities.
- Pay attention to walking, running or working surfaces.
- Wear good shoes with appropriate support.
- Pay attention to your body’s warning signs to slow down when you feel pain or fatigue.
- Use an ankle brace when performing activities with lateral motions.
- Custom Molded Orthotics
How is an Ankle Fracture Treated?
Dr. Soomekh educates that early diagnosis and treatment of an ankle fracture is the key to successful treatment, faster recovery and painless lifestyle. Patients that sustain an ankle sprain and potential fracture and “walk it off” or postpone treatment are more likely to incur chronic pain and loss of function.
Conservative Treatment for an Ankle Fracture:
Conservative treatments rely on their ability to stabilize the fracture and the ankle ligaments and joints and reduce pain and swelling. If the fracture is mild, the bones are well, aligned, and the joint is stable, conservative treatment is warranted.
The patient is placed into a cast non-weight bearing on crutches for up to 6 weeks. A walking boot is used for 2 weeks after the cast. Physical therapy will begin once the cast is removed as an integral part of the healing process. Custom orthotics will be recommended to support the injured area.
Unhealthy or at risk patients that suffer a severe fracture where surgery would normally be warranted, may be given conservative treatment.
Pain and significant swelling will usually last two days to three days. During the first 2 weeks it is recommended to use ice therapy and non-steroidal anti-inflammatories (NSAID’s) to reduce the pain and swelling.
Surgical Treatment for an Ankle Fracture:
Dr. Soomekh will always recommend and attempt conservative treatment when appropriate. However, when an ankle fracture is severe, unstable or misaligned surgical repair may be indicated.
Is Ankle Surgery Painful?
Considering surgery can be intimidating. Ankle surgery including surgery to correct ankle fractures is not supposed to be painful during recovery. When the skin and the soft tissues are handled with care and focus, most patients experience little to no pain immediately after surgery and throughout the recovery period. Dr. Soomekh takes great care and focus to minimize the chance of postoperative pain.
The goal of ankle fracture surgery is to realign the bones and joints into their anatomical position, stabilize the fracture during the healing time, and allow a return to all activities. Dr. Soomekh performs the procedures in an outpatient setting at state of the art facilities.
How do I Choose the Right Surgeon?
Dr. Soomekh has significant experience in every aspect of ankle surgery. He is able to choose the exacting correct procedure for each individual patient because he has innovated and perfected the techniques for ankle repair. He uses the most advanced equipment and materials available. He understands the importance of identifying every nuance of the fracture and its impact on the patient. Dr. Soomekh will use the information gained from the patient’s symptoms, age, activity level, lifestyle goals, the severity of the fracture, the clinical examination, x-rays, and CT scans to make a recommendation on the proper procedure.
Open Reduction and Internal Fixation (ORIF):
When the ankle fracture is out of place or the ankle joint is unstable, the fracture will need to be treated with surgery. During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The bones are then held together with special screws and metal plates attached to the outer surfaces of the bone (internal fixation). The implants hold the bones together during the healing process and compress the bones to facilitate healing. Once the bones heal in 6 weeks, the screws and plate are not needed. Generally they are left in place. In rare cases they can be removed if needed.
In some cases, surgery may be considered even if the fracture is not out of place. This is done to reduce the risk of the fracture not healing (called a nonunion), and to allow you to start moving the ankle earlier.
When the syndesmotic ligament is torn alone or with an associated fracture, a special anchor and heavy stich system is used to reinforce the ligament.
Dr. Soomekh will use the latest technology when repairing an ankle fracture. Some patient may benefit from stem cell therapy to augment the fracture repair.
Ankle fracture repair will require a 4 to 6 week period in a cast and crutches. A walking boot is used to transition into walking for 2 to 3 weeks. Physical therapy is integral in the healing process.
Dr. Soomekh has perfected and reinvented these surgical procedures and techniques and is recognized by his peers as one of the top Ankle specialists and Ankle surgeons in Los the Angeles area.