Outer ankle fracture

Synonyms

Fibular fracture, malleolar fracture, bimalleolar fracture, trimalleolar fracture, Weber fractures, fracture of the fibula, outer ankle fracture,

definition

Ankle fractures like the lateral ankle fracture are fractures of the ankle joint with varying degrees of severity. Both the inner and outer ankles can be affected. With 10% of fractures, they are the third most common fracture in humans.

causes

The outer malleolus fracture is the result of a traumatic dislocation in over 80% of cases (Subluxation / dislocation) of the ankle bone from the joint-forming ankle fork, usually caused by a misstep or fall (ankle injury). Direct violence as a cause is rare.

Depending on the position of the foot at the moment of the injury and the magnitude of the force acting, different injury patterns occur (see classifications).

Symptoms

The outer ankle fracture is the most common injury to the upper ankle.
The through the fracture of the outer ankle (fracture) -related symptoms basically depend on the type of injury and the structures involved in the ankle. On the one hand, it is important to distinguish at which level the break is.

The doctor uses the tape that ultimately holds the two ankles together. On the other hand, ligaments or, less often, bones on the inner ankle, which can be overstretched or torn, can also be involved in every fracture of the outer ankle.

Typical symptoms are swelling with redness or bruising on the affected foot, pain when stepping on the foot or when touching the ankle. There may be a restriction of movement or a complete inability to put weight on the foot at all, with a possible unstable feeling. In some cases, an external malleolus fracture leads to malposition of the joint or sensory disturbances in the affected area.

Read more on the topic:

• Symptoms of an external malleolus fracture
• Outer ankle pain

Definition of terms

1. Malleolar fracture = outer or inner ankle fracture
2. Bimalleolar fracture = outer and inner ankle fractures
3. Trimalleolar fracture = outer and inner ankle fractures plus fracture of the posterior edge of the tibia (rear Volkmann triangle)

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Athletes (joggers, soccer players, etc.) are particularly often affected by diseases of the foot. In some cases, the cause of the foot discomfort cannot be identified at first.
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classification

The most common classification of ankle / fibular fractures in everyday clinical practice is that according to Danis and Weber (Weber 1966). It relates exclusively to the fracture height of the fibula in relation to the syndesmosis:

1. Weber A: fracture of the tip of the lateral malleolus below the syndsmosis. Syndesmosis always intact.
2. Weber B: fracture of the lateral malleolus at the level of the syndesmosis. Syndesmosis mostly injured, but not necessarily with resulting instability of the ankle joint.
3. Weber C: fracture of the lateral malleolus above the syndesmosis. Syndesmosis always torn with resulting instability of the ankle joint.

If not only the outer malleolus is affected by the fracture, differentiate between:

• Bimalleolar fracture
• Trimalleolar fracture
• Comminuted fractures: Destruction of the bony ankle joint with involvement of the inner and outer ankle as well as the pilon tibiale (tibia).

With the AO classification (Working Group on Osteosynthesis), all fracture forms of the ankle joint can be precisely classified:

A fracture: ankle fracture below the syndesmosis

• A1 Simple lateral malleolus fracture
• A2 outer and inner malleolus fractures
• A3 outer and inner ankle fractures with postero-medial fracture

B fracture: ankle fracture at the level of the syndesmosis

• B1 Simple outer malleolus fracture
• B2 external and internal malleolus fractures
• B3 outer and inner ankle fractures with postero-lateral fracture (Volkmann triangle)

C fractures: ankle fracture above the syndesmosis

• C1 Simple diaphyseal fibular fracture
• C2 Diaphyseal fibular fracture, multi-fragment
• C3 Proximal fibular fracture

The classification according to Lauge-Hansen (1950) differentiates between 4 types of dislocation fractures and takes into account the position of the foot at the time of the accident, as well as the direction and extent of the acting force:

• Supination adduction fracture (twisting over the outer edge of the foot)
• Pronation-abduction fracture (twisting over the inner edge of the foot = less often)
• Supination-eversion fracture (2/3 of all fractures) = injury mechanism like a ligament tear
• Pronation-eversion fracture

Diagnosis

If there is justified suspicion of an ankle fracture, an X-ray of the ankle joint in two planes (from the front (a.p. image) and from the side) should always be performed. This is important for confirming the suspected diagnosis, assessing the extent and type of the fracture, diagnosing the possibility of other injuries and planning therapeutic measures.

If a fibula injury near the knee is suspected (Maisonneuve fracture), the entire lower leg should be x-rayed in two planes (is sometimes overlooked!).

If the tibia carrying the ankle (pilon tibiale) is involved in the fracture, computed tomography (CT) of the ankle can be useful for better evaluation of the fracture and treatment planning.

Treatment with OP

Surgical treatment of the lateral malleolus fracture is generally recommended, unless the fracture is very uncomplicated or the risks of an operation are too high for the respective patient.

There are guidelines for deciding when to break the outer leg bone (Fibula) should be treated surgically, but the individual assessment should not be missing. If the break is at the level of the ligament that connects the two bones in the lower leg at the lower end and ultimately holds the ankle together (Syndesmosis) and if this ligamentous connection is itself partially damaged by a non-continuous tear, for example, this would be a reason for surgical treatment. Please refer: Syndesmoser crack

In medicine, this constellation is called a "Weber type B" external malleolus fracture. Another case, namely a "Weber Type C" fracture, is also an occasion for an operation.
The band-like connection (Syndesmosis) completely torn, the fracture is localized over the syndesmosis mentioned and a thin skin (membrane) between the two lower leg bones is also torn.
Another case for an operation is a simple break below the syndesmosis without further damage if the two fragments have shifted too far against each other (dislocated fracture) and the break would no longer heal normally naturally. Then the bones must be surgically returned to their original position. The operation itself and the aids used also depend on the type of fracture, a possible ligament injury and the stability of the ankle.

Displaced bone parts are usually placed next to each other and connected and stabilized with screws or metal plates (Fixation). It is important to restore the exact length of the outer bone, otherwise the foot will be incorrectly positioned in the long term. Torn ligaments are sewn together and, if necessary, fixed with an additional "set screw" that is removed after about six weeks.

In the case of complicated fractures, such as the type B or C mentioned above, “lag screws” and metal plates are often used in combination. In contrast to set screws, lag screws can exert pressure on the fracture gap by permanently pressing both bone parts together, which increases bone healing. Plates, on the other hand, stabilize and support the fracture from the side and thus prevent the bone parts from shifting during the healing process.
In severe cases, such as an open fracture in which the bone parts protrude from the skin or a debris fracture in which many small free bone parts can be seen, the temporary use of a so-called "external fixator", which acts like a scaffold, may be necessary that holds the fractions in place from the outside. In any case, it is only used for the first emergency treatment, which is always followed by a definitive, final treatment as described above.

More on the topic Operation of an external malleolus fracture read here.

Non-surgical treatment

Non-surgical or conservative therapy for an external ankle fracture (Ankle fracture) is a good alternative to surgery, which of course carries the general risks of surgery.
The prerequisite for the non-surgical treatment of an external malleolus fracture is that the fracture is uncomplicated and stable.

A bone fracture is said to be stable if the fragments are not shifted against each other, the fracture line is as straight and smooth as possible, no bone parts have splintered and the bones involved are not too far apart.
In the special case of an ankle fracture, such a stable fracture, which can usually be treated without surgery, is called a Weber A fracture.

The non-operative therapy then looks like this:

First, the ankle is cooled to reduce bleeding and swelling. If the swelling on the ankle has successfully subsided, a plaster cast is placed around the foot including ankle and lower leg, which ensures that the joint is immobilized for up to 6 weeks.
In general, it may well be allowed on the medical side in the case of an uncomplicated Weber A fracture to fully load the affected foot with plaster within the healing time. Stepping on and walking on or with the injured ankle can be advisable if the fracture is held in the correct position by means of a cast from the outside, as the pressure on the edges of the fracture promotes the healing process.

More complicated fractures of the outer ankle are mainly treated surgically, but this is not recommended in exceptional cases, such as a known circulatory disorder that makes an operation too risky.
In such a case, a plaster of paris is used to immobilize the patient for 6 weeks, but the affected person has to gradually feel his way to a full load under the supervision of a doctor.

The healing process of the fracture is assessed by means of regular x-ray controls and the appropriate time for the plaster removal is determined.

Read more on the topic: Treating the external ankle fracture without surgery

complication

Complications can occur with conservative therapy as with the operation of the lateral ankle fracture.

Complications with conservative therapy:

• Slipping of the fracture (Secondary dislocation)
• Pressure damage from plaster of paris
• False joint formation (pseudarthrosis)
• Sudeck's disease

Complications with operative therapy:

• Vascular, tendon and nerve injuries
• infection
• (Slipping of the fracture)
• Implant loosening
• False joint formation (pseudarthrosis)
• Sudeck's disease
• Thrombosis / pulmonary embolism

Perspective / forecast

Regardless of the type of fracture, the prognosis for regaining a permanently functional ankle is good. Precondition is an exact fracture device and the creation of natural (anatomical) ankle conditions.

A smooth gait pattern should be regained around eight weeks after the operation, and cycling and swimming are possible. Very stressful ankle sports such as football and tennis can be resumed after approx. 3-6 months.

Duration

The healing time of an external malleolus fracture is fundamentally individual and depends on the type of fracture, its stability and condition, the age and level of activity of the patient and of course any accompanying injuries to the surrounding structures.

If the treatment is non-operative, the plaster cast can usually be expected to remain in place for about six weeks. This time is an average value, which in turn depends on the age and the corresponding healing speed of the bone.
With increasing age, fractures heal more slowly and the bone substance is not always fully resilient immediately.

However, as with almost any fracture, prolonged immobilization does not necessarily produce better results. The foot should gradually be loaded again with the help of physiotherapy and exercises until, in the best case, it reaches the original level of functionality. In order to be able to correctly assess the healing process in individual cases, regular x-ray check-ups usually take place.
Activities that place extreme stress on the ankle, such as certain sports, can be forbidden by the doctor for a few months after the treatment. After an operative therapy, the procedure is almost identical, in addition, materials such as nails and screws are left in the bone for up to a year until they are removed.

More information on the topic Healing time of an external malleolus fracture read here.