What is it?
A fracture is a partial or complete break in a bone. In the ankle, fractures involve the far or distal ends of the tibia, the fibula, or both bones. The tibia is the shinbone and is located on the inner, or medial, side of the leg. The fibula is located on the outer, or lateral, side of the leg. The distal ends of the tibia and fibula bones are also known as the medial and lateral malleoli, respectively.
Some distal tibia fractures can involve the rear or posterior part of the bone, which are also known as posterior malleolar fractures. Ankle fractures can range from the less serious avulsion injuries (small pieces of bone that have been pulled off) to severe, shattering-type breaks. Some fractures may also involve injuries to important ankle ligaments that keep the ankle in its normal position. Ankle fractures are commonly caused by the ankle twisting inward or outward.
What are the treatment options?
Elevation and Ice
Swelling is often seen after an ankle fracture. By limiting the amount of swelling, the pain from the ankle fracture can be decreased and further damage to the surrounding soft tissue may be prevented. Elevating the ankle and icing the affected area can help to limit swelling.
A splint may need to be placed to support the broken ankle. The splint usually remains for several days. A splint allows for room to accommodate swelling. If the damaged ankle is not displaced, the splint may be applied immediately without moving the broken ankle. However, if the bones are displaced and/or the ankle joint is dislocated, a closed reduction is performed while the splint is placed. This treatment involves setting the tibia and/or fibula bones and ankle joint to improve the position and pain at the ankle. This treatment may require some type of anesthesia.
Rest/No Weight Bearing
Most patients require some period of rest with no weight being put upon the ankle. Crutches, walkers and wheelchairs allow patients to keep weight off of the ankle. Many factors can determine the best choice for each individual patient. The type of ankle fracture will determine when patients can start to stand and walk on their injured ankle. In many cases, a patient will not be able to place any weight on the ankle for several days, weeks or even months. This is a determination that must be made by an orthopedic foot and ankle specialist.
Cast/Fracture Boot Immobilization
Some ankle fractures can be treated without surgery. These are usually injuries where one bone is minimally displaced. Such fractures can be treated simply with a period of immobilization. Once the initial swelling improves over the first several days, either a cast or a fracture boot can be applied to the ankle to properly protect and immobilize it. Both a cast and a boot can provide adequate protection to the ankle. A cast cannot get wet or be removed without special tools. A boot can be removed for bathing and sleeping. The type of fracture and the physician’s judgment will determine the best type of immobilization. The cast or boot is worn until the fracture is fully healed, which usually takes two to three months.
Whether or not a patient requires surgery will largely depend on the appearance of the ankle joint on the X-ray and the specific type of fracture. Badly displaced fractures and fractures of both the tibia and fibula commonly need surgery. Restoring alignment of the broken bone is essential to full recovery because ankle arthritis can occur if a fracture heals improperly. The best way to minimize the risk of arthritis is to restore the ankle to as close to normal as possible.
The surgical treatment is known as an open reduction and internal fixation or ORIF. An outer or lateral incision is made at the ankle if the fibula bone is broken. An inner or medial incision is made at the ankle if the distal tibia bone is broken. The injured bones are set properly through these incisions and kept in place with metal plates and screws. As the ankle heals after surgery, the joint is protected with restricted activity and a cast or fracture boot. The cast or boot is worn until the fracture is fully healed.
If surgery is required, the ankle is stabilized internally with either screws, pins, plates or a combination of these to stabilize the fracture and allow for best possible healing.
Fractures that extend into the joint do put you at a slight risk for arthritis in the future.
What to Expect
The day of the procedure, you will need to arrange for a ride to and from the procedure and arrange for help at home.
Wear shorts or loose pants and a t-shirt for surgery.
Do not eat or drink anything after midnight for arrivals before noon. Otherwise, do not eat or drink anything seven hours prior to your arrival at the surgery center.
If crutches or a walker are needed, please rent or borrow them prior to your surgery.
You will be contacted by Lawrence Surgery Center to set up your patient account. They will inform you of your pre-operative instructions as well as tell you when to arrive for surgery.
You will likely be placed in a cast and be unable to put weight through your involved lower extremity for six weeks or more. Your physician will likely schedule follow up appointments that include x-rays to check for proper healing and to ensure that the bones have not shifted in any way.
• You may resume your regular diet. However, start slow with clear liquids and gradually work your way back to your normal diet. This will help prevent nausea and vomiting.
Ankle Care & Bathing
• Use your crutches and do not place any weight on your operated leg! This is important!
• Keep your ankle elevated above heart level as much as possible for the first five days, then as needed when symptomatic for up to two weeks. This will prevent painful swelling and promote healing.
• Keep your splint clean and dry all the time.
• It is ok to shower or sponge bath two days after surgery but you must keep your splint clean and dry at all cost! This usually entails wrapping your ankle in a plastic garbage bag to keep it dry.
• To help reduce pain and swelling, apply an ice pack to the surgical area for 20 to 25 minutes every one to two hours for the first 48-96 hours and then as needed to help control pain and swelling.
• To avoid frostbite, place a towel or t-shirt between the ice pack and your skin.
• It is not necessary to use ice while sleeping.
• We recommend the use of a cold therapy unit, which is often an out of pocket expense. The advantage of this unit is that the temperature can be regulated, allowing for continuous use for several hours at a time.
• Your physician will give you a written prescription for pain medicine as you leave the surgery center. Take your pain medication as prescribed. You may want to take it regularly for the first 48 hours after surgery. Do not take any additional Tylenol.
• While you are asleep in the operating room, a long acting numbing medication may be injected into the surgical area to help relieve your immediate postoperative discomfort for up to 24 hours. When you first notice tingling or throbbing, begin taking your pain medicine so it will become effective before the local anesthesia wears off.
• No driving while taking any narcotic pain medication!
• The pain medication may cause some nausea so take it with food.
• The pain medication and general anesthesia may also cause constipation, so you may need to take a stool softener, fiber bar, Metamucil or prune juice to prevent constipation.
• Watch for temperature > 101.5F, persistent numbness and tingling in the foot, persistent bleeding or drainage from the wound, foul odor, progressively worsening pain that is unresponsive to pain medication, blue toes, chest pain or difficulty breathing. If you have any of these symptoms, call the office if during normal business hours or go to the nearest emergency room.
• If you do not have a postoperative appointment set-up already, please call the office to schedule an appointment for 7-10 days after surgery at (785)843-9125.
Rehabilitation Plan- Exercises
Physical therapy is often prescribed following the immobilization period due to loss of range of motion and strength about the ankle. Exercises will include range of motion activities, band exercises to restore stability about the ankle, balance activities to improve proprioception and progression back to normal activity.