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Ankle Fracture Differential Diagnosis: A Comprehensive Guide for Accurate Assessment

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Introduction

Ankle fractures represent a significant portion of orthopedic injuries, ranging from minor incidents in elderly individuals to severe trauma in younger, active populations. Effective management hinges on precise diagnosis, appropriate classification, and tailored treatment strategies aimed at restoring joint stability and minimizing the long-term risk of post-traumatic ankle arthritis.12 This article provides an in-depth review of ankle fractures, emphasizing the critical aspect of differential diagnosis to ensure accurate assessment and optimal patient care. We will explore the anatomy, etiology, epidemiology, pathophysiology, evaluation, and management of ankle fractures, with a particular focus on distinguishing them from other conditions that may present with similar symptoms.

Anatomy of the Ankle Joint

Understanding the intricate anatomy of the ankle joint is crucial for comprehending ankle fracture patterns and their differential diagnosis. The ankle joint, a synovial hinge joint, primarily facilitates dorsiflexion and plantar flexion.3 It is formed by the articulation of three bones: the distal tibia, distal fibula, and talus. The distal tibia and fibula together form the ankle mortise, a socket-like structure that houses the talus.3 This joint complex includes three malleoli:

  • Lateral Malleolus: The distal end of the fibula.
  • Medial Malleolus: The medial lower end of the tibia.
  • Posterior Malleolus: The posterior aspect of the distal tibia.

Ankle stability is maintained by several key structures:

  • Ankle Mortise Articulation: The precise fit of the talus within the tibial and fibular malleoli.
  • Ankle Syndesmosis: A fibrous joint connecting the distal tibia and fibula, composed of the interosseous tibiofibular ligament, anterior inferior tibiofibular ligament, and posterior inferior tibiofibular ligament.4
  • Deltoid Ligament: A strong ligament complex on the medial side of the ankle, originating from the medial malleolus and attaching to the talus, navicular, and calcaneus. It resists excessive ankle eversion.5
  • Lateral Ligament Complex: Located on the lateral side, consisting of the anterior talofibular ligament, posterior talofibular ligament, and calcaneofibular ligament, all originating from the lateral malleolus. This complex prevents excessive ankle inversion.5
  • Surrounding Muscles and Tendons: Provide dynamic stability and support to the ankle joint.

The ankle joint receives innervation from articular branches of the tibial, superficial peroneal, and deep peroneal nerves. Blood supply is derived from branches of the peroneal, anterior tibial, and posterior tibial arteries.6

Etiology of Ankle Fractures

Ankle fractures are typically caused by traumatic forces applied to the ankle joint. Common mechanisms include:

  • Twisting Injuries: These often occur during falls, missteps, or sports activities, resulting in rotational forces across the ankle.
  • Impact Injuries: High-energy trauma, such as falls from height or motor vehicle accidents, can cause direct impaction of the distal tibia and fibula against the talus.
  • Crush Injuries: Heavy objects or road traffic accidents can lead to severe crush injuries of the ankle, often with extensive soft tissue damage and comminuted fractures.

The severity of the fracture, including the degree of bony comminution and associated soft tissue injury, is directly related to the energy of the traumatic event.

Epidemiology of Ankle Fractures

Ankle fractures are a prevalent orthopedic injury. Epidemiological studies indicate:

  • The annual incidence is approximately 187 ankle fractures per 100,000 adults.7
  • Incidence peaks in older women (75-84 years) and younger men (15-24 years).8
  • Unimalleolar fractures are the most common type (around 70%), followed by bimalleolar (20%) and trimalleolar fractures (7%).8
  • Open ankle fractures account for about 2% of all ankle fractures.8

These statistics underscore the importance of understanding ankle fractures and their management within the context of general orthopedic practice and emergency medicine.

Pathophysiology and Classification of Ankle Fractures

The ankle joint and its surrounding ligaments form a complete ring. Disruption of this ring typically occurs at two points. Therefore, a comprehensive evaluation of ankle fractures necessitates assessing the entire ankle ring to identify all bony and ligamentous injuries. Several classification systems are used to categorize ankle fractures, guiding treatment decisions and prognosis.

Anatomical Classification

This system classifies fractures based on the location of the bony injury:

  • Isolated Medial Malleolus Fracture: Fracture of the medial malleolus alone.
  • Isolated Lateral Malleolus Fracture: Fracture of the lateral malleolus alone.
  • Bimalleolar Ankle Fracture: Fractures of two malleoli, typically the medial and lateral malleoli. Less commonly, it may involve the posterior and lateral malleoli.
  • Trimalleolar Ankle Fracture: Fractures of all three malleoli: medial, lateral, and posterior.

Danis-Weber Classification

The Danis-Weber system categorizes fractures based on the level of the fibular fracture relative to the syndesmosis:

  • Weber Type A: Fibular fracture below the level of the syndesmosis. These fractures are often stable and may be treated non-operatively.
  • Weber Type B: Fibular fracture at the level of the syndesmosis. Stability varies; stable Weber B fractures without deltoid or syndesmotic injury can be managed conservatively, while unstable fractures require surgical fixation.
  • Weber Type C: Fibular fracture above the level of the syndesmosis. These fractures are usually unstable, indicating syndesmotic injury and often deltoid ligament disruption, requiring surgical stabilization.9

Lauge-Hansen Classification

The Lauge-Hansen classification is based on the position of the foot at the time of injury and the direction of the force applied. It describes four main types, with each type further divided into stages reflecting the sequence of ligament and bone injury.10

  • Supination-Adduction (SA):

    1. Transverse fracture of the distal fibula.
    2. Vertical fracture of the medial malleolus.

  • Supination-External Rotation (SER): (Most common ankle injury, ~60% of fractures)

    1. Anterior inferior tibiofibular ligament injury.
    2. Spiral or oblique fracture of the distal fibula.
    3. Posterior inferior tibiofibular ligament injury or posterior malleolus avulsion.
    4. Fracture of the medial malleolus or deltoid ligament injury.

  • Pronation-External Rotation (PER):

    1. Fracture of the medial malleolus or deltoid ligament injury.
    2. Anterior inferior tibiofibular ligament injury.
    3. Spiral or oblique fracture of the fibula (proximal to the tibial plafond).
    4. Posterior inferior tibiofibular ligament injury or posterior malleolus avulsion.

  • Pronation-Abduction (PA):

    1. Fracture of the medial malleolus or deltoid ligament injury.
    2. Anterior inferior tibiofibular ligament injury.
    3. Comminuted or transverse fibular fracture (proximal to the tibial plafond).

In the Lauge-Hansen system, injuries occur in a progressive manner; a SER4 injury includes all stages from SER1 to SER3.10

Other Specific Ankle Fracture Types

  • Maisonneuve Injury: An unstable ankle injury resulting from pronation-external rotation, characterized by a proximal fibular fracture combined with tibiofibular syndesmosis and deltoid ligament injury, often with or without a medial malleolus fracture. Surgical intervention is typically required due to its instability.11
  • Pilon Fracture: A comminuted fracture of the tibial plafond (distal articular surface of the tibia), usually caused by high-energy axial loading, such as a fall from height, leading to talar impaction against the tibia.12
  • Bosworth Fracture-Dislocation: A rare ankle fracture-dislocation where the fibula is posteriorly dislocated and locked behind the posterior tibial border, requiring surgical reduction and fixation.13

History and Physical Examination in Ankle Fractures

A thorough history and physical examination are essential for evaluating ankle injuries and guiding differential diagnosis.

History

Key aspects of the patient’s history include:

  • Medical History: Comorbidities such as diabetes, peripheral vascular disease, neuropathy, inflammatory joint diseases, obesity, and kidney disease can affect fracture healing and prognosis. Uncontrolled diabetes and vascular disease increase the risk of complications like Charcot arthropathy. Pre-existing conditions should be optimized prior to surgical intervention.
  • Social History: Patient’s pre-injury mobility level, living situation, activity level, and functional goals are important for setting realistic rehabilitation expectations. Smoking and excessive alcohol consumption can impair fracture and wound healing.
  • Mechanism of Injury: Understanding how the injury occurred (twisting, impact, crush) helps determine the likely fracture pattern and severity. High-energy mechanisms raise suspicion for compartment syndrome or pilon fractures. The ankle position and direction of force at the time of injury are crucial for applying the Lauge-Hansen classification.
  • Venous Thromboembolism (VTE) Risk Assessment: All ankle fracture patients should be assessed for VTE risk factors (smoking, prior DVT, family history, obesity, hormonal therapy, oral contraceptives) to determine the need for thromboprophylaxis.

Physical Examination

A systematic physical exam is crucial:

  1. Adult Trauma Life Support (ATLS) Primary and Secondary Survey: In trauma settings, always follow ATLS protocols to rule out life-threatening injuries before focusing on the ankle. This includes Airway, Breathing, Circulation, Disability, and Exposure (A-E).14
  2. Neurovascular Assessment: Documented neurovascular assessment before and after any manipulation is mandatory. Assess foot color, temperature (pallor and coldness indicate vascular compromise), and distal pulses (dorsalis pedis and posterior tibial, comparing to the uninjured side). If vascular compromise is suspected, immediate ankle reduction should be attempted. Neurological assessment should include motor and sensory function of the peroneal (deep and superficial), tibial, sural, and plantar nerves.
  3. Soft Tissue Assessment: Evaluate for skin integrity, swelling, blisters, and open wounds. Threatened skin or significant deformity requires urgent reduction and splinting to minimize soft tissue complications.
  4. Proximal Fibula Examination: Palpate the proximal fibula and knee to rule out Maisonneuve fractures, which involve proximal fibular fractures.
  5. Ottawa Ankle Rules: Utilize the Ottawa Ankle Rules to guide the need for radiography, reducing unnecessary X-rays. Radiographs are indicated if there is pain in the malleolar region AND any of the following:
    • Bone tenderness at the posterior edge or tip of either malleolus (within 6 cm).
    • Inability to bear weight immediately after injury and in the emergency department (defined as taking four steps).15

Diagnostic Imaging for Ankle Fractures

Appropriate imaging is essential for confirming the diagnosis and characterizing ankle fractures.

  1. Plain Radiographs: X-rays are the initial imaging modality for ankle injuries. Obtain anteroposterior (AP), lateral, and mortise views. Do not delay urgent reduction for radiographs in cases of obvious ankle deformity and neurovascular compromise.

    • AP View: Assess for soft tissue swelling and subtle fractures.
    • Lateral View: Evaluate the posterior malleolus and talar dome position relative to the mortise, checking for anterior or posterior dislocations.
    • Mortise View: Crucial for assessing the ankle mortise (tibial plafond, malleoli, talar dome) and syndesmosis. Obtained with 15-20 degrees of internal rotation and ankle dorsiflexion. A normal mortise view shows uniform joint space width.16
    • Weight-Bearing and Stress Views: Indicated to assess stability and rule out deltoid ligament or syndesmotic injuries, particularly in Weber B fractures.
    • Full Tibia and Fibula Length X-rays: Necessary to rule out proximal fibular fractures in suspected Maisonneuve injuries.

  2. Computed Tomography (CT Scan): CT scans are valuable for complex ankle fractures to assess articular surface involvement, fracture configuration, and comminution, aiding in preoperative planning. CT is also useful for detailed evaluation of posterior malleolar fractures.17

  3. Magnetic Resonance Imaging (MRI): MRI is primarily used to evaluate soft tissue injuries, including ligament sprains (deltoid, lateral collateral complex, syndesmosis), chondral lesions, and stress fractures. MRI is not routinely needed for acute ankle fracture diagnosis but can be helpful in specific scenarios or for chronic ankle pain after injury.

Treatment and Management of Ankle Fractures

The primary goal of ankle fracture treatment is to restore ankle mortise stability, which can be achieved through non-operative or operative methods, depending on fracture stability.18

Non-operative Treatment

Indications:

  1. Stable ankle fractures, such as isolated unimalleolar fractures without talar shift on weight-bearing radiographs.
  2. Patients unfit for surgery or who decline surgical intervention.
  3. Cases with poor soft tissue conditions that increase surgical risks.

Non-operative Methods:

  1. Below Knee Cast: For stable fractures, cast immobilization allows fracture healing.
  2. Closed Reduction and Cast Application: May be considered for unstable fractures in older or medically compromised patients. Reduction is performed under image guidance, followed by close contact cast application.19
  3. Walking Boot: May be used in the later stages of healing or for certain stable, minimally displaced fractures.
  4. Analgesia: Adequate pain management is essential throughout non-operative treatment.

Operative Treatment: Open Reduction and Internal Fixation (ORIF)

Indications for ORIF:

  • Failed closed reduction or neurovascular compromise in ankle fracture-dislocations.
  • Unstable ankle fractures in patients fit for surgery and with acceptable soft tissue conditions.
  • Specific fracture patterns:
    1. Unimalleolar fractures with talar shift on weight-bearing radiographs.
    2. Bimalleolar and trimalleolar ankle fractures.
    3. Pilon fractures.
    4. Maisonneuve fractures.

Surgical Timing: ORIF is typically performed within 24 hours of injury or delayed for a few days to allow soft tissue swelling to subside, reducing wound complications.

ORIF Techniques:

  • Fibular Fracture Fixation: Plates and screws are commonly used. Fibular nails may be preferred for comminuted fractures or poor bone quality.
  • Medial Malleolus Fracture Fixation: Transverse fractures are often fixed with partially threaded screws or tension band wiring. Vertical medial malleolus fractures may require buttress plating using an anti-glide plate.
  • Posterior Malleolus Fracture Fixation: Posterior-to-anterior lag screws or anti-glide plates can be used.
  • Syndesmosis Assessment and Fixation: Intraoperative assessment of syndesmotic stability is crucial, often using the Hook test (Cotton test) or intraoperative stress external rotation views.2021 A positive Hook test (>2mm fibular displacement) indicates syndesmotic injury and the need for reduction and fixation with syndesmotic screws or tightropes.22

Spanning External Fixator

External fixation may be used as a temporary measure for unstable ankle fractures with significant soft tissue swelling or open fractures. It stabilizes the ankle mortise, allowing soft tissue healing before definitive ORIF in a staged approach. External fixator pins should be placed away from planned surgical approaches for subsequent ORIF.

Ankle Fracture Differential Diagnosis

Accurate differential diagnosis is crucial in managing ankle injuries. Several conditions can mimic ankle fractures, requiring careful clinical and radiographic evaluation. The key differential diagnoses to consider include:

  1. Ankle Sprains (Lateral and Medial Ligament Sprains):

    • Presentation: Ankle sprains, particularly lateral ligament sprains, are very common and can present with pain, swelling, and difficulty weight-bearing, similar to ankle fractures. Medial (deltoid) ligament sprains are less frequent but can also mimic fractures.
    • Differentiation:
      • Mechanism of Injury: Sprains often result from inversion or eversion injuries without high-energy impact.
      • Physical Exam: Tenderness in sprains is typically localized to ligamentous structures rather than bony prominences. Ottawa Ankle Rules help guide radiography, but sprains can also meet criteria for X-rays if severity is uncertain. Ligamentous laxity on stress testing may be present in sprains.
      • Imaging: Plain radiographs are usually negative in sprains (except for avulsion fractures, which are technically fractures). MRI can confirm ligament injuries but is not routinely needed in acute sprains unless fracture is ruled out and persistent symptoms warrant further investigation.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Distinguishing ankle sprains from subtle ankle fractures is a primary focus of ankle fracture differential diagnosis. Clinical judgment and selective use of imaging are crucial.

  2. Tendon Ruptures (Achilles Tendon Rupture, Peroneal Tendon Rupture):

    • Presentation: Achilles tendon rupture typically presents with sudden, sharp pain in the posterior ankle, often described as feeling a “pop” or “snap.” Patients may have difficulty with plantar flexion and weight-bearing. Peroneal tendon ruptures can cause lateral ankle pain and instability.
    • Differentiation:
      • History: Achilles rupture often has a characteristic history of sudden onset during push-off or eccentric loading.
      • Physical Exam: Achilles rupture may have a palpable gap in the tendon, positive Simmonds’ test (Thompson test – lack of plantar flexion when calf is squeezed in prone position), and weakness in plantar flexion. Peroneal tendon rupture may show tenderness along peroneal tendons and weakness in eversion.
      • Imaging: X-rays are negative in tendon ruptures. Ultrasound or MRI can confirm tendon tears and are useful if clinical diagnosis is uncertain.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Tendon ruptures, particularly Achilles tendon rupture, are important in the differential diagnosis of posterior ankle pain and functional impairment after injury, sometimes mimicking posterior malleolus fractures or trimalleolar injuries.

  3. Osteochondral Lesions of the Talus (OLT):

    • Presentation: OLTs may present acutely after trauma or insidiously with chronic ankle pain, catching, clicking, and swelling. Acute OLTs after ankle trauma can be mistaken for fractures.
    • Differentiation:
      • History: Acute OLTs occur with trauma, but chronic OLTs may develop without a clear injury.
      • Physical Exam: Tenderness over the anterolateral or anteromedial talar dome. Mechanical symptoms like catching or locking suggest OLT.
      • Imaging: Plain radiographs may show OLTs in later stages, but MRI is the best modality for visualizing cartilage and subchondral bone, essential for diagnosing and staging OLTs. CT can also be used to assess bony aspects of OLTs.
      • Ankle Fracture Differential Diagnosis Keyword Integration: In the acute setting, OLTs need to be considered, especially if pain and swelling persist despite negative initial fracture radiographs, or if there is suspicion of intra-articular injury.

  4. Foot Fractures (Calcaneus Fracture, Talus Fracture, Metatarsal Fractures):

    • Presentation: Fractures of the calcaneus, talus, or metatarsals can cause pain, swelling, and difficulty weight-bearing in the foot and ankle region, potentially mimicking distal ankle fractures.
    • Differentiation:
      • Physical Exam: Careful palpation to localize tenderness. Calcaneal fractures cause heel pain, talus fractures cause pain around the talar neck or body, and metatarsal fractures cause forefoot pain.
      • Imaging: Foot radiographs are needed to diagnose foot fractures. Calcaneal fractures often require axial calcaneal views and CT for surgical planning. Talus fractures may require specific talar views and CT/MRI for detailed assessment.
      • Ankle Fracture Differential Diagnosis Keyword Integration: While anatomically distinct, foot fractures must be considered in the differential diagnosis of lower extremity injuries presenting with pain and limited weight-bearing after trauma. Ottawa Ankle Rules are helpful for ankle radiography, but Ottawa Foot Rules guide foot radiography when foot pain is present.

  5. Lisfranc Injuries:

    • Presentation: Lisfranc injuries involve fractures and/or ligamentous disruption of the tarsometatarsal joint complex. They can present with midfoot pain, swelling, bruising (plantar ecchymosis), and difficulty weight-bearing. High-energy Lisfranc injuries can extend proximally, causing pain that may be confused with ankle injury.
    • Differentiation:
      • Mechanism of Injury: Often axial loading or twisting forces on a plantarflexed foot.
      • Physical Exam: Tenderness over the midfoot, pain with pronation/supination of the forefoot while stabilizing the hindfoot (“piano key test”), midfoot swelling and plantar bruising.
      • Imaging: Weight-bearing foot radiographs are crucial for diagnosing Lisfranc injuries, looking for subtle malalignment or widening of the tarsometatarsal joints. CT is often needed for surgical planning and to assess complex injuries.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Proximal Lisfranc injuries can sometimes present with pain radiating towards the ankle, making them part of the differential diagnosis, especially when midfoot findings are subtle on initial exam.

  6. Soft Tissue Contusions and Hematomas:

    • Presentation: Direct trauma without fracture can cause significant soft tissue contusion and hematoma, leading to pain, swelling, and ecchymosis around the ankle.
    • Differentiation:
      • Physical Exam: Tenderness is diffuse and soft tissue-based, without bony tenderness according to Ottawa Ankle Rules. Range of motion may be limited by pain but is not structurally blocked.
      • Imaging: Radiographs are negative. Ultrasound may show hematoma but is usually not necessary.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Soft tissue injuries are a common reason for ankle pain after trauma. Ruling out fracture with radiographs is essential, and clinical follow-up confirms resolution of symptoms with conservative management.

  7. Gout and Pseudogout:

    • Presentation: Acute gout or pseudogout can cause sudden onset of severe joint pain, swelling, warmth, and redness in the ankle, mimicking inflammatory fracture complications or infection.
    • Differentiation:
      • History: Prior episodes of gout, known hyperuricemia, or other risk factors.
      • Physical Exam: Signs of inflammation are prominent (redness, warmth). May have pain with even gentle touch (exquisite tenderness).
      • Investigations: Serum uric acid levels (for gout), joint aspiration and synovial fluid analysis (crystal identification, cell count, gram stain to rule out infection) are diagnostic. Radiographs are usually normal initially but may show chronic changes with repeated gout attacks.
      • Ankle Fracture Differential Diagnosis Keyword Integration: While less directly related to trauma, acute inflammatory arthritis can present with acute ankle pain requiring differential diagnosis, especially if the onset is sudden and after minimal or unnoticed trauma.

  8. Septic Arthritis and Cellulitis:

    • Presentation: Infection of the ankle joint (septic arthritis) or surrounding soft tissues (cellulitis) can cause pain, swelling, redness, warmth, and fever. These can be considered in the differential diagnosis if there is concern for infection, especially in open fractures or patients with risk factors.
    • Differentiation:
      • Clinical Features: Systemic signs of infection (fever, chills, malaise). Cellulitis shows spreading redness, warmth, and skin changes. Septic arthritis is characterized by joint effusion, severe pain with passive motion, and reluctance to weight-bear.
      • Investigations: Blood tests (WBC count, ESR, CRP) may be elevated. Joint aspiration is crucial for septic arthritis (synovial fluid analysis for cell count, gram stain, culture and sensitivity). Radiographs are usually non-diagnostic acutely but are needed to rule out fracture and monitor for osteomyelitis later.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Infection is a less common but serious consideration in the differential diagnosis of ankle pain and swelling, especially in open fractures or patients with risk factors for infection. Prompt recognition and treatment are crucial.

  9. Nerve Entrapment Syndromes (Tarsal Tunnel Syndrome):

    • Presentation: Tarsal tunnel syndrome (compression of the tibial nerve in the tarsal tunnel) can cause pain, numbness, and tingling in the medial ankle and plantar aspect of the foot. While not typically mimicking acute fractures, chronic nerve pain might be considered in persistent pain after ankle injury when fractures have healed.
    • Differentiation:
      • History: Pain is often neuropathic (burning, tingling), may radiate, and can be aggravated by activity or prolonged standing.
      • Physical Exam: Tinel’s sign (tapping over the tarsal tunnel reproduces symptoms), sensory changes in the tibial nerve distribution, weakness of intrinsic foot muscles in advanced cases.
      • Investigations: Nerve conduction studies (NCS) and electromyography (EMG) can confirm nerve compression. MRI may be used to rule out space-occupying lesions in the tarsal tunnel.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Nerve entrapment is less likely to mimic acute fracture presentation but should be considered in the differential diagnosis of persistent pain after ankle trauma, especially if neuropathic symptoms are present.

  10. Plantar Fasciitis:

    • Presentation: Plantar fasciitis causes heel pain that is typically worse in the morning or after rest, improving with activity. Pain is localized to the plantar heel but can sometimes radiate to the ankle.
    • Differentiation:
      • History: Gradual onset of heel pain, characteristic morning pain.
      • Physical Exam: Tenderness to palpation at the plantar medial calcaneal tubercle. Dorsiflexion of the foot and toes may exacerbate pain. Ankle examination is usually normal.
      • Imaging: Radiographs are usually not needed for plantar fasciitis. Ultrasound may show plantar fascia thickening.
      • Ankle Fracture Differential Diagnosis Keyword Integration: Plantar fasciitis is less likely to be confused with acute ankle fracture due to its typical heel pain presentation, but referred pain patterns could rarely cause diagnostic confusion in some patients.

Prognosis of Ankle Fractures

Prognosis for ankle fractures varies depending on fracture stability, severity, and treatment approach.

  • Stable Fractures (Non-operative Management): Patients with stable fractures typically have an excellent prognosis, often returning to baseline function within 6-8 weeks with gradual weight-bearing and rehabilitation.
  • Unstable Fractures (ORIF): Even with surgical fixation and anatomical reduction, full functional recovery may take longer, and the risk of post-traumatic ankle arthritis remains. Studies report post-traumatic arthritis incidence around 14% even with optimal surgical management, potentially due to initial chondral injury.23

Complications of Ankle Fractures

Complications can occur with both non-operative and operative management of ankle fractures.24

Non-operative Complications

  1. Ankle stiffness.
  2. Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).
  3. Ankle mortise redislocation.
  4. Skin ulceration from cast pressure.
  5. Delayed union or non-union.
  6. Malunion.
  7. Chronic ankle instability.
  8. Delayed return to function.
  9. Post-traumatic ankle arthritis.

Operative Complications

  1. Infection (superficial or deep).
  2. Painful scar.
  3. Wound dehiscence.
  4. Metalwork failure (breakage, loosening).
  5. Malpositioned hardware (screw protrusion).
  6. Prominent hardware causing irritation.
  7. Delayed union or non-union.
  8. Nerve injury (e.g., superficial peroneal nerve).
  9. Vascular injury (rare).

Charcot Arthropathy: A specific complication in diabetic patients, Charcot arthropathy involves progressive joint degeneration, bone destruction, and deformity, potentially leading to ulceration, infection, and amputation.

Deterrence and Patient Education

Patient education is vital in ankle fracture management.

  • Stable Fractures: Educate patients about follow-up, expected healing course, weight-bearing progression, and signs of delayed healing or complications requiring reassessment.
  • Surgical Management: Discuss the importance of physical therapy, weight-bearing protocols, wound care, and red flags for complications. Pre-operative and post-operative education enhances patient compliance and outcomes.

Pearls and Key Considerations in Ankle Fracture Management

  • Always perform ATLS primary and secondary surveys in trauma patients to rule out life-threatening injuries before focusing on ankle fractures.
  • Thorough neurovascular and soft tissue assessment is essential.
  • Urgent reduction is required for ankle fracture-dislocations with neurovascular compromise or skin tenting.
  • Utilize appropriate imaging to confirm diagnosis and classify fracture patterns.
  • Assess neurovascular status before and after reduction and splinting.
  • Be aware of accessory ossicles around the ankle, which can be mistaken for avulsion fractures.

Enhancing Healthcare Team Outcomes

Optimal management of ankle fractures requires a multidisciplinary approach.

  • Trauma Team Activation: High-energy trauma cases necessitate a full trauma team (trauma leader, ED physician, surgeon, anesthesiologist, radiographer, nurses) following ATLS principles. Ankle fracture management should not overshadow the assessment for other life-threatening injuries.
  • Interprofessional Communication: Effective communication among team members is crucial, especially for procedural sedation, surgical planning, and post-operative care.
  • Physical Therapy: Physical therapists play a key role in post-injury rehabilitation, guiding range of motion, strengthening, and weight-bearing progression.
  • Discharge Planning: Case managers facilitate discharge planning, ensuring patients have necessary equipment (walkers, canes), home nursing if needed, thromboprophylaxis, and appropriate follow-up appointments with orthopedics and physiotherapy.

Conclusion

Accurate diagnosis and effective management of ankle fractures are critical for optimal patient outcomes. A comprehensive understanding of ankle anatomy, injury mechanisms, classification systems, and treatment options is essential. Crucially, a robust approach to ankle fracture differential diagnosis ensures that other conditions mimicking ankle fractures are considered and appropriately ruled out, leading to precise diagnosis and tailored management strategies. A multidisciplinary healthcare team approach further enhances care coordination and improves outcomes for patients with ankle fractures.

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