Ankle Fractures in Adults

4/1/23, 20:11 Ankle fractures in adults - UpToDate
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Ankle fractures in adults

Author: Scott M Koehler, MD
Section Editors: Chad A Asplund, MD, MPH, FAMSSM, Matthew Gammons, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2022. | This topic last updated: Apr 06, 2022.
INTRODUCTION
Ankle fractures are increasingly common injuries that necessitate a careful approach for
proper management. Over five million ankle injuries occur each year in the United States
alone [1].
This topic review will provide an overview of ankle fractures that result from minor trauma
(ie, indirect or low energy fractures), including a basic approach to their evaluation and
management. Fibular fractures above the lateral malleolus, tibial fractures, and ankle
injuries other than fractures are discussed elsewhere. (See "Fibula fractures" and "Overview
of tibial fractures in adults" and "Ankle sprain in adults: Evaluation and diagnosis" and "Non-
Achilles ankle tendinopathy".)
EPIDEMIOLOGY AND RISK FACTORS
The incidence of ankle fractures is approximately 187 fractures per 100,000 people each year
[1]. Since the mid-1900s, this rate has increased significantly in many industrialized
countries, most likely due to growth in the number of people involved in athletics and in the
size of the elderly population [1-3].
The vast majority of ankle fractures are malleolar fractures: 60 to 70 percent occur as
unimalleolar fractures, 15 to 20 percent as bimalleolar fractures, and 7 to 12 percent as
trimalleolar fractures [1,4]. There are similar fracture rates overall between women and men,
but men have a higher rate as young adults, while women have higher rates in the 50- to 70-
year age group [1,4].
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Cigarette smoking and a high body mass index have been associated with ankle fractures
[5,6]. In contrast to fractures of the radius and other fractures common among
perimenopausal and postmenopausal women, bone density has not been clearly
demonstrated to be a major risk factor [7].
CLINICAL ANATOMY
The bony anatomy of the ankle consists of the articulation of the distal tibia and fibula with
the talus ( figure 1 and figure 2 and figure 3). These bones are held together by the
ligaments of the ankle to form a mortise. The weight-bearing portion of the mortise consists
of the tibial plafond and the talar dome. The mortise gains its stability from the bony
relationships of the ankle and from surrounding structures.
The lateral ligament complex consists of the anterior talofibular ligament, the
calcaneofibular ligament, and the posterior talofibular ligament ( figure 4). The medial
ankle complex consists of the deep and superficial fibers of the deltoid ligament
( figure 5). The peroneal tendons, anterior and posterior tibialis tendons, Achilles tendon,
and joint capsule provide additional support ( figure 6).
The syndesmosis of the ankle refers to the articulation of the distal tibia and fibula
( figure 7). Support is provided by the anterior tibiofibular ligament, the posterior
tibiofibular ligament, the transverse tibiofibular ligament (posteriorly), and the interosseous
membrane, which extends from the ankle proximally. These structures prevent the distal
tibia and fibula from separating. Abnormal forces that rotate the talus within the mortise
push the tibia and fibula apart and may cause an injury to the syndesmotic ligaments or a
fracture.
The motion of the ankle is complex. Although the joint moves primarily in the sagittal plane
to enable dorsiflexion and plantarflexion of the foot, motion occurs in several planes.
Inversion and eversion of the foot occur mainly at the subtalar joint.
The talar dome is narrower posteriorly. It therefore fits more tightly into the mortise,
creating greater joint stability, when the ankle is dorsiflexed [3,8]. The position of the talus in
the mortise depends more on the medial supporting structures, which are stronger, than the
lateral structures. Therefore, the ankle is better able to withstand forces that stress the
medial side of the joint [9].
The posterior tibial artery and tibial nerve run together just posterior and lateral to the
medial malleolus ( figure 8). The anterior tibial artery (dorsalis pedis in the foot) and deep
peroneal nerve run together and cross the ankle joint anteriorly, approximately in the
midline, just lateral to the extensor hallucis longus and below the extensor retinaculum.

There is no single, widely accepted definition of the anatomic margins of the lateral
malleolus. For the purpose of this review, the lateral malleolus refers to the distal part of the
fibula that articulates with the talus and distal tibia. Lateral malleolar fractures are those that
lie between the distal tip of the fibula and the most proximal portion of the fibula that lies
directly adjacent to the tibia in the tibial groove ( image 1).
The lateral malleolus provides stability against excessive eversion of the ankle and foot. The
medial malleolus is the most distal part of the tibia and articulates with the medial aspect of
the talar dome. The posterior aspect of the distal tibia is commonly referred to as the
posterior malleolus. It primarily includes the portion of the tibia where the syndesmotic
ligament complex attaches.
MECHANISM OF INJURY
Overview — Ankle injuries that result from bending forces are commonly described as
inversion or eversion injuries. Technically, inversion and eversion are motions of the subtalar
joint and become supination and pronation when combined with ankle and midfoot motion.
Internal and external rotation of the ankle refers to the rotation of the talus within the joint.
Supination (inversion) injuries typically cause distraction of the lateral ankle structures and
compression of the medial structures. Pronation (eversion) injuries cause medial distraction
and lateral compression. Structures being distracted (or stretched) generally fracture or tear
before structures being compressed. As an example, injuries that occur while the ankle is
supinated will result in damage to the distal fibula and its associated ligaments, which are
being stretched, before any damage occurs to the distal tibia and its deltoid ligament
complex.
In addition to bending forces, rotational forces often contribute to ankle injuries by placing
further stress on supporting structures and forcing the malleoli apart.
Historically, orthopedists have classified the mechanism of injury using two descriptors. The
first describes the position of the ankle at the time of injury; the second refers to the force
applied to the ankle that causes the injury. As an example, a "supination/external rotation"
injury refers to the ankle in a supinated position with an external rotation force applied to it.
These descriptors predict the sequence in which structures are injured and provide the basis
for the Lauge-Hansen system of ankle fracture classification used to guide orthopedic
decision making. The amount of force sustained during the injury is a third factor, in addition
to ankle position and force direction, which determines the type and extent of injury.
Several studies question the accuracy of the Lauge-Hansen scheme [10,11]. A complete
discussion of classification systems is beyond the scope of this review and can be found

elsewhere [3,9,12].
One classification scheme deserves further mention because of its simplicity and clinical
relevance. In this approach, the ankle is conceived as a ring of supporting structures
surrounding the talus ( figure 9) [8]. Supporting structures may be ligaments or bones. If
the ring is broken at one site, the injury is stable and can be managed nonoperatively; if the
ring is broken at two or more sites, the injury is unstable and is managed operatively.
Malleolar fractures — Isolated malleolar fractures tend to be stable if they are

nondisplaced (ie, no significant contralateral injury of ligaments or bone and no syndesmotic
injury). However, care must be taken with fractures of the medial malleolus. Disruption of
lateral or posterior structures often occurs in association with these fractures, though they
may initially appear to be isolated injuries.
Posterior malleolar fractures occur either from the impact of the talus on the posterior
aspect of the tibia (often as part of a pilon fracture ( image 2)) or from an external rotation
or pronation (eversion) force. They occur in association with disruption of the posterior
tibiofibular ligament. Posterior malleolar fractures rarely occur in isolation [13]. They are
more commonly associated with fibular fractures and additional ligament damage, and they
are generally unstable injuries.
Fractures of both the lateral and medial malleoli are called bimalleolar fractures and are
generally unstable. A bimalleolar fracture with a fracture of the posterior malleolus is
referred to as a trimalleolar fracture. Trimalleolar fractures are unstable and typically occur
with injuries of greater force. They have a higher risk of complication than bimalleolar
fractures and require surgical stabilization.
CLINICAL PRESENTATION AND EXAMINATION
Emergency conditions, such as an open fracture, neurovascular compromise, or fracture

dislocation, must be treated immediately. (See 'Initial treatment' below.)
In addition to the mechanism of injury, the clinician’s history should ascertain the following:
● Site of the most significant pain

● Other injured areas (eg, lumbar spine, hip, knee)
● Length of time from injury to presentation
● Neurovascular symptoms
● Ability to bear weight
● History of any previous injury or surgery
● Related comorbidities (eg, diabetes)

An ankle fracture, particularly one sustained in a fall, may mask other injuries such as a
lumbar compression fracture.
Clinicians should inspect the injured ankle for:
● Swelling
● Deformity
● Skin abnormalities, such as lacerations (possible open fracture), tenting, or blistering
(caused by rapid stretching of the skin)
The amount of swelling is not a reliable guide to the presence of a fracture.
Clinicians should palpate the ankle looking for the point of maximal tenderness and other
tender areas. The examiner should palpate the tibia and fibula, especially the fibular neck, to
evaluate for possible associated fractures. Testing for ligamentous laxity can be deferred
until after radiographs are obtained; it is often not tolerated in the setting of an acute
fracture.
Pulses of the dorsalis pedis and posterior tibialis arteries and distal capillary refill should be
checked. Sensation and motor function should be assessed. A detailed discussion of the
physical examination of the ankle is found elsewhere. (See "Ankle sprain in adults: Evaluation
and diagnosis".)
Once emergency conditions have been ruled out, the first priority in the evaluation of ankle
fractures is to determine whether the fracture is stable, and can be managed nonoperatively,
or unstable, and must be referred. Typically, an ankle fracture is stable if it meets the
following criteria:
● It is isolated to the lateral, medial, or posterior malleolus

● It is nondisplaced and at or below the level of the mortise
● It is not associated with a ligamentous injury
An ankle fracture is unstable if two or more sites of significant injury are present, such as a
lateral malleolar fracture with deltoid ligament disruption or a bimalleolar fracture. (See
'Indications for orthopedic consultation or referral' below.)
DIAGNOSTIC IMAGING
The Ottawa ankle rules have been shown to help the examiner in determining if radiographs
of the ankle or foot are needed in the evaluation of an acute ankle injury ( figure 10).
Patients who do not meet the Ottawa criteria are unlikely to have a fracture, and
radiographs are typically not needed in the acute setting [14]. A full discussion of the Ottawa
rules is found elsewhere. (See "Ankle sprain in adults: Evaluation and diagnosis", section on
'Ottawa ankle rules'.)
Ankle fractures are typically evaluated using plain radiographs. Anterior-posterior (AP),
oblique, and lateral views are standard. The oblique radiograph, also called the mortise view,
should be obtained as an AP projection with a 10 to 20 degree lateral angle to help visualize
injuries of the syndesmosis and talus ( image 3). On the mortise view, the relationship of
the medial and lateral malleoli can be measured with respect to the talus. Normally, the
distances between the talus and the lateral malleolus, the talus and the medial malleolus,
and the talus and the tibial plafond are uniform throughout the mortise.
Isolated lateral and medial malleolar fractures are best seen on the AP view ( image 4 and
image 5). Posterior malleolar fractures are best seen on the lateral view ( image 6 and
image 7). On the mortise view, discrepancies in the relationship between the talus and
the medial and lateral malleoli can help identify an unstable fracture or soft tissue injury
( image 8 and image 9).
The presence of medial injury determines the stability of lateral malleolar fractures. Stress
radiographs are needed to determine the stability of the joint in cases of a lateral malleolar
fracture with deltoid ligament tenderness but no widening of the joint on initial radiographs.
Deltoid ligament injury is assumed if a distance greater than 4 mm is measured between the
talus and the medial malleolus on either a standard mortise or stress radiograph
( image 9) [12,15]. Adequate external rotation of the foot is necessary for obtaining
accurate stress radiographs. Clinicians should avoid inflicting undue pain when obtaining
such studies by providing adequate analgesia and limiting the force applied when this
causes excessive discomfort. If adequate stress radiographs cannot be obtained, the patient
should be referred for specialty consultation.
The gravity stress mortise radiograph has been shown to be as sensitive and specific as a
manual stress mortise radiograph ( picture 1) [15,16]. A decision about surgical
intervention should not be based on stress radiographs alone. The integrity of the deltoid
ligament can be further assessed with magnetic resonance imaging (MRI) or ultrasound [17]
if necessary.
Isolated medial malleolar and isolated posterior malleolar fractures are considered stable if
no associated injury or tibiotalar joint displacement is present, fracture displacement is
equal to 2 mm or less, and joint surface involvement is less than 25 percent [9,12,13]. In the
case of isolated posterior malleolar fractures, no displacement on a lateral radiograph is
acceptable. If it is unclear whether displacement is present on plain radiograph, a CT scan
should be obtained [18].

If a fracture of the talus is suspected, or if significant comminution is present, a CT scan will

further delineate the extent of the injury and identify fracture displacement. If plain films are
negative and clinical suspicion is high for specific soft tissue or cartilage injuries, MRI is more
useful ( image 10 and figure 3). Both MRI and triple-phase bone scintigraphy (bone
scan) ( image 11) are helpful in diagnosing a stress fracture in the ankle region, especially
if plain radiographs are normal. (See "Overview of stress fractures".)
INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
Open fractures and any injury with associated neurologic or vascular deficits require
immediate surgical referral.
The two major indications for operative fixation of an ankle fracture are loss of joint
congruency or loss of joint stability [3,9,12]. Loss of joint congruency, such as occurs with
severe posterior malleolar fractures and pilon fractures, occurs in the setting of more severe
trauma (pilon fractures occur when relatively strong axial forces drive the tibial plafond into
the talar dome ( image 2)). Fractures that create joint instability as a result of minor
trauma are more common.
Typically, an ankle fracture is unstable if two sites of significant injury are present. All
trimalleolar, bimalleolar, and isolated malleolar fractures with an opposing ligament rupture
(eg, a lateral malleolar fracture with deltoid ligament disruption) are unstable and require
orthopedic referral. If there is any uncertainty about the stability of the ankle, the patient
should be referred. Unstable fractures are generally managed surgically although, in some
instances at centers with appropriate expertise, may be treated with molded casting [19].
Injuries that lead to a distal fibular fracture above the tibiotalar joint line are almost always
associated with a syndesmotic disruption and should be referred to an orthopedist
( image 12 and image 13 and image 14). Posterior malleolar fractures that result in
loss of joint congruency should also be referred.
Unstable fractures often require open reduction with internal fixation. Whether operative or
nonoperative management is used, the goal of treatment is anatomic alignment to
maximize function and minimize the risk of post-traumatic osteoarthritis.
TREATMENT
Initial treatment — Emergency conditions, such as an open fracture or neurovascular

impairment, require immediate surgical consultation and treatment. Fracture dislocations
must be reduced immediately to prevent severe complications, such as avascular necrosis.

Once emergency conditions are excluded, clinicians should evaluate the fracture more
closely, focusing on any malalignment or instability, to determine proper management and
follow-up (see 'Indications for orthopedic consultation or referral' above). The ankle should
be splinted at 90 degrees (ie, neutral position) to provide support and control pain. Usually, a
short-leg posterior splint is sufficient. A sugar-tong (ie, coaptation) splint can be added for
additional mediolateral support. If significant swelling or deformity is present, adequate
padding should be placed prior to application of the splint to allow for further swelling, while
maintaining stability.
Clinicians should instruct the patient to call immediately for:
● Pain that is severe or increasing

● Numbness that is new or worsening
● Skin discoloration (eg, dusky toes) distal to the splint
These complaints may represent vascular compromise or some other serious complication
and should be investigated immediately. Any patient complaint of skin irritation, a splint
which has become excessively tight or loose, or a splint which has gotten wet should also be
assessed. An examination and repeat radiographs to check for acceptable alignment are
generally performed during the first follow-up visit at 7 to 10 days.
For stable, nondisplaced, isolated malleolar fractures, the patient should rest, elevate the
involved ankle above the level of the heart, and apply ice, while keeping the splint dry. The
importance of elevating the leg should be emphasized to patients, as complications with
splint treatment often stem from allowing the foot to remain in a dependent position for too
long.
Patients awaiting orthopedic consultation or surgery should remain nonweightbearing in a

splint (as described above), apply ice while keeping the splint dry, and use pain medication
as needed. If surgery is planned in the acute setting, excessive use of narcotic analgesics
should be avoided, if possible, until the orthopedic surgeon is able to explain the procedure
and obtain informed consent. Management of specific fracture types is discussed
immediately below.
Management of specific malleolar fractures — There is little high quality evidence to

determine the best treatment of ankle fractures [20]. Our recommendations below are
based upon limited randomized trials, observational data, and clinical experience.
Lateral malleolar fractures — Fracture stability determines treatment. The location of an

isolated lateral malleolar fracture in relationship to the joint can help to determine if the
fracture is stable. Lateral malleolar fractures below the level of the tibiotalar joint line (ie,
mortise) ( image 15) are typically stable and less likely to be associated with additional

ligament injuries. When an ankle injury causes a fracture above the level of the mortise
( image 12 and image 13 and image 14), it is typically unstable due to the associated
syndesmosis injury and must be referred for surgical evaluation. (See 'Indications for
orthopedic consultation or referral' above.)
The stability of fractures at the level of the mortise ( image 4 and image 9 and
image 16) depends upon the integrity of the medial structures (mainly the deep deltoid
ligament and the medial malleolus) [14]. The presence of a lateral malleolar fracture
together with a medial fracture or deltoid ligament injury significantly increases the risk of
joint instability, even if alignment is well maintained ( image 8) [12].
Instability is demonstrated by 2 mm or more of displacement of the fibular fracture, an

associated medial fracture, or a medial ligament disruption, all of which should prompt
orthopedic referral ( image 9). Medial swelling, ecchymosis, and tenderness, suggests the
possibility of medial ligament injury and requires orthopedic consultation. Uncertainty about
the stability of medial structures indicates the need for stress radiographs, such as the
gravity stress mortise view ( picture 1), to determine the degree of instability [15]. If
medial instability is demonstrated or suspected, orthopedic referral is obtained. If the medial
structures are intact and there is minimal fibular displacement, non-surgical treatment has a
high success rate [21,22]. Stress radiographs are described above. (See 'Diagnostic imaging'
above.)
Two long-term follow-up studies of patients with isolated lateral malleolar fractures at or
below the level of the ankle joint reported that greater than 90 percent of patients had good
clinical results regardless of treatment, provided fibular displacement did not exceed 3 mm
[21,22]. Other studies comparing operative with nonoperative treatment of isolated lateral
malleolar fractures have shown no significant difference in outcomes [5-7,9,23]. Based upon
such studies, treatment for isolated lateral malleolar fractures is primarily nonoperative.
If the fracture consists solely of a small, nondisplaced transverse avulsion fragment, the
patient may be treated like a patient with a severe ankle sprain, ie, with early motion,
bracing, and gradual rehabilitation ( image 15). (See "Ankle sprain in adults: Evaluation and
diagnosis".)
If the isolated fracture is oblique through the lateral malleolus at or below the mortise, and
there is no sign of instability, the patient may be treated in a short-leg walking cast or
removable cast boot, in neutral position, for three to six weeks, weight-bearing as tolerated
( image 16). Treatment in a removable cast boot causes less discomfort and loss of
mobility, and no change in long-term outcomes, according to a small number of clinical trials
[24,25]. The results of another randomized trial suggest that immobilization for three weeks
in a short-leg walking cast or properly fitting rigid ankle orthosis further reduces the short-
term loss of ankle mobility and the risk for deep vein thrombosis compared with treatment
in a short-leg walking cast for six weeks, without compromising healing [26]. While further
study is needed to confirm the effectiveness of limiting immobilization to three weeks,
evidence in support of shorter periods of immobilization is growing.
Radiographs should be repeated 7 to 10 days after the injury for oblique fractures to ensure
that alignment remains acceptable and again at four to six weeks to assess healing [12]. An
examination of the ankle, including palpation for medial tenderness, should also be
performed at these time intervals. In most cases, healing can be assessed clinically. Once
healing is evident (ie, nontender over the fracture site with radiographic evidence of
adequate callus around the fracture), the patient may begin unsupported weight-bearing
and gradual rehabilitation. If healing is insufficient, the ankle should be immobilized or
braced for an additional two weeks and then reassessed. Persistent pain and a lack of callus
formation should prompt orthopedic referral.
Treatment of fractures of the proximal fibula and fibular shaft are discussed elsewhere. (See
"Fibula fractures".)
Isolated medial or posterior malleolar fractures — Care must be taken with these

fractures to confirm the absence of associated injuries. Fractures with associated injuries,
such as a proximal fibular fracture, are referred. If there is concern for ligament injury in
addition to the fracture, the patient should also be referred for orthopedic consultation. If
the fractures are truly nondisplaced, isolated injuries, they can be treated initially in a splint
( image 5). Patients should not bear weight until their initial follow-up visit.
Seven to ten days following the injury, patients are re-evaluated, including repeat
radiographs to confirm alignment. If the isolated nature of the injury is confirmed by
examination and radiograph, the patient can be placed in a walking cast or walking boot.
The cast or boot should hold the ankle at 90 degrees to prevent a flexion contracture.
Patients remain in the cast or boot, weight-bearing as tolerated, for four to six weeks.
Radiographs are repeated four weeks after the injury and subsequently every two weeks
until the fracture is clinically healed (ie, nontender over the fracture site with radiographic
evidence of adequate callus around the fracture). Once clinically healed, patients should
begin a gentle rehabilitation program.
Lateral malleolar fractures with deltoid ligament injury — A lateral malleolar fracture
with disruption of the deltoid ligament is unstable and is managed no differently than a
bimalleolar fracture ( image 9). The instability associated with these injuries has been
confirmed in outcome studies and cadaveric research models [12]. Anatomic reduction of
the ankle with surgical stabilization leads to better clinical results [12]. Patients with this
injury should be splinted with the ankle joint at 90 degrees, remain nonweightbearing, and
be referred to an orthopedist within a few days.
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Bimalleolar and trimalleolar fractures — These fractures are unstable and require

operative fixation. Patients should be splinted with the ankle joint at 90 degrees, remain
nonweightbearing, and be referred to an orthopedist within a few days ( image 8 and
image 17).
REHABILITATION AFTER ANKLE FRACTURE
The goal of rehabilitation after an ankle fracture is to restore any loss of motion, strength, or
proprioception that may have occurred as a result of the injury or the subsequent
immobilization and disuse related to treatment. There is little evidence that any specific
rehabilitation program improves clinical outcome [9]. It is possible that individuals may
return to their preinjury level of activity more quickly with aggressive rehabilitation. Research
about early weight-bearing and physical therapy is on-going. For most ankle fractures,
rehabilitation can be carried out with a basic home exercise program of stretching, range of
motion, strengthening, and balance exercises [27].
A systematic review of 38 controlled trials related to the rehabilitation of ankle fractures

found the evidence to be of limited quality and noted the following [28]:
● Early performance of ankle exercises following surgical fixation improved ankle

function and mobility, while decreasing pain, but was associated with higher rates of
adverse events (eg, surgical wound complications), although most problems were
minor. Use of a removable immobilization device was necessary for this approach. For
protocols involving early exercise, the authors emphasized the importance of the
patient’s ability to comply with the regimen safely and precisely.
● Early ambulation following surgical repair may improve ankle motion, but studies
supporting this approach are small and contradictory.
● Neither stretching nor manual therapy (passive motion exercises performed by a

trained professional) appeared to improve function following the immobilization period
regardless of whether management was surgical or conservative.
● Treatment with electrical or thermal stimulation devices or with ultrasound was not
supported by high quality evidence.
COMPLICATIONS
Ankle fractures have a relatively low complication rate when managed appropriately in
patients without comorbidities. Complication rates in patients with significant comorbidities
(eg, diabetes or peripheral vascular disease) or behaviors known to impair fracture healing

(eg, smoking) are higher [29,30]. (See 'Indications for orthopedic consultation or referral'
above and 'Treatment' above and "General principles of fracture management: Early and late
complications".)
Acute complications of ankle fractures, such as injuries to peripheral nerves or vascular

structures, open fractures, and compartment syndrome, are readily identified in most cases
and require immediate surgical consultation. Nerve injury can occur at the time of injury
from lacerations caused by fracture fragments, direct contusion, or traction, but may also
occur during subsequent treatment from casting or splinting materials that compress the
nerve. Injuries to the lateral ankle or pressure on the proximal fibula from a cast or splint
may lead to peroneal nerve injury causing weak foot dorsiflexion; injuries to the medial
ankle may lead to tibial nerve injury. (See "Overview of lower extremity peripheral nerve
syndromes", section on 'Fibular (peroneal) nerve' and "Overview of lower extremity
peripheral nerve syndromes", section on 'Tibial nerve'.)
Lower extremity compartment syndrome is less likely to occur from ankle fractures than
from fractures of the diaphysis of the tibia or fibula. Nevertheless, any patient complaining
of increasing pain or new numbness and tingling or other symptoms concerning for
compartment syndrome during treatment for an ankle injury should be examined without
delay. (See "Acute compartment syndrome of the extremities", section on 'Clinical features'.)
Venous thromboembolism (VTE) is an infrequent complication, particularly of fractures

managed nonoperatively, but occurs more often in older adults and patients with a history
of VTE [31]. In an observational study of over 86,000 patients with ankle fractures requiring
immobilization, VTE occurred in 1.3 percent of patients within 90 days. While low, this rate
was approximately sixfold greater than among matched patients with hand wounds and
wrist fractures.
Occasionally, skin damage can occur from stretching or abrasions incurred at the time of
injury or from subsequent splinting and casting. Blisters and abrasions should be followed
closely until they heal because of the risk of cellulitis.
Potential chronic complications of ankle fractures include instability, osteoarthritis, and pain.
Failure to recognize a syndesmotic injury that accompanies a fibular fracture above the ankle
joint may lead to instability and premature osteoarthritis ( image 18). In addition, a missed
medial ligament injury in the setting of a lateral malleolar fracture can lead to instability,
which can progress to joint pain and degeneration of the articular surface. While less than
five percent of patients with unimalleolar fractures develop degenerative changes,
detectable several years later by radiograph, as many as 20 percent of patients with
bimalleolar fractures develop such radiographic findings [9].

Nonunion or malunion of ankle fractures is uncommon in healthy patients. Nevertheless,

orthopedic referral is generally needed if a fracture does not appear to be healing as
expected by eight weeks following the injury. Inadequate healing is suggested by persistent
or worsening pain or tenderness at the fracture site, or by signs of inadequate healing on
plain radiographs. Orthopedic referral is necessary if the fracture displaces during the
course of treatment.
If functional deficits (eg, restricted motion) persist despite appropriate management and
rehabilitation, reevaluation for associated injuries, such as ligament or tendon disruption, or
osteochondral injury, should be performed. Orthopedic consultation or imaging with MRI
may be needed in such cases.
Complex regional pain syndrome (CRPS) may develop in the days or weeks following an
ankle fracture. Pain from CRPS is more severe than that expected from the inciting injury and
is often associated with such findings as abnormal skin color, temperature change,
diminished motor function, and edema ( picture 2 and picture 3). Early identification
and treatment of CRPS is important. (See "Complex regional pain syndrome in adults:
Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)
Diabetic patients have an increased risk of complications after ankle fracture [12,29]. Skin
injury, postoperative infection, and malunion occur more frequently in diabetics. We suggest
more frequent clinic visits (every two to three weeks), including careful skin examination and
radiographs, for these patients.
According to retrospective reviews, elderly patients generally have more complex fracture
patterns when compared to those under age 65 and are more prone to postoperative
complications [32,33]. However, overall functional outcomes among patients above and
below 65 years are similar when baseline function and the complexity of the fracture are
taken into account.
ADDITIONAL INFORMATION
Several UpToDate topics provide additional information about fractures, including the
physiology of fracture healing, how to describe radiographs of fractures to consultants,
acute and definitive fracture care (including how to make a cast), and the complications
associated with fractures. These topics can be accessed using the links below:
● (See "General principles of fracture management: Bone healing and fracture

description".)
● (See "General principles of fracture management: Fracture patterns and description in
children".)

● (See "General principles of acute fracture management".)

● (See "General principles of definitive fracture management".)
● (See "General principles of fracture management: Early and late complications".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Lower extremity
(excluding hip) fractures in adults" and "Society guideline links: Acute pain management".)
INFORMATION FOR PATIENTS
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and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Ankle fracture (The Basics)" and "Patient
education: Fractures (The Basics)" and "Patient education: Caring for your cast (The
Basics)" and "Patient education: Using crutches (The Basics)")
● Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
● Epidemiology and mechanism – The great majority of ankle fractures are malleolar
fractures; 60 to 70 percent are unimalleolar. Supination (inversion) injuries typically
cause distraction (stretching) of the lateral ankle structures and compression of the
medial structures. Pronation (eversion) injuries cause medial distraction and lateral
compression. Structures being distracted generally fracture or tear before structures

being compressed. (See 'Epidemiology and risk factors' above and 'Clinical anatomy'
above and 'Mechanism of injury' above.)
● Indications for referral – Open fractures and any injury with associated neurologic or
vascular deficits require immediate orthopedic referral. Fracture dislocations require
rapid reduction and referral. Unstable injuries should be referred within a few days.
(See 'Indications for orthopedic consultation or referral' above.)
● Physical examination – Ankle fractures, particularly ones sustained in a fall, may mask
other injuries. Especially with cases involving older adults or significant trauma, be sure
to palpate the lumbar spine, hip, tibia, fibula (especially the fibular neck), and foot to
check for associated injuries. (See 'Clinical presentation and examination' above.)
● Stable versus unstable injury – Once emergency conditions have been ruled out, the
first priority is to determine whether the fracture is stable, and can be managed
nonoperatively, or unstable, and must be referred. Typically, an ankle fracture is stable
if it meets the following criteria:
• It is isolated to the lateral, medial, or posterior malleolus

• It is nondisplaced and at or below the level of the mortise
• It is not associated with a ligamentous injury
An ankle fracture is unstable if two or more sites of significant injury are present, such
as a lateral malleolar fracture with deltoid ligament disruption or a bimalleolar fracture.
(See 'Clinical presentation and examination' above and 'Indications for orthopedic
consultation or referral' above.)
● Diagnostic imaging – The Ottawa ankle rules help to determine whether radiographs
of the ankle or foot are needed in the evaluation of an acute ankle injury ( figure 10).
Anterior-posterior (AP), oblique, and lateral radiographs are the standard views
obtained if imaging is necessary. (See 'Diagnostic imaging' above.)
● Initial care – Initial management of ankle fractures consists of splinting, ice, elevation
above the level of the heart, and analgesics. The ankle should be splinted at 90
degrees. Usually, a short-leg posterior splint is sufficient. (See 'Initial treatment' above.)
● Management – Unstable ankle fractures often require surgical repair. Management of

the major types of ankle fractures is discussed in the text. The goal of rehabilitation is
to restore any loss of motion, strength, or proprioception that may have occurred. (See
'Management of specific malleolar fractures' above and 'Rehabilitation after ankle
fracture' above.)
Use of UpToDate is subject to the Terms of Use.

REFERENCES
1. Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in
Rochester, Minnesota. Acta Orthop Scand 1987; 58:539.
2. Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiology of ankle fractures. A
prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop
Scand 1998; 69:48.
3. Marsh, JL, Saltzman, CL. Ankle Fractures. In: Rockwood and Green's Fractures in Adults,
Bucholz, RW and Heckman, JD (Eds), Lippincott Williams and Wilkins, Philadelphia 2002.
p.2001.
4. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?

Acta Orthop Scand 1998; 69:43.
5. Valtola A, Honkanen R, Kröger H, et al. Lifestyle and other factors predict ankle fractures
in perimenopausal women: a population-based prospective cohort study. Bone 2002;
30:238.
6. Honkanen R, Tuppurainen M, Kröger H, et al. Relationships between risk factors and
fractures differ by type of fracture: a population-based study of 12,192 perimenopausal
women. Osteoporos Int 1998; 8:25.
7. Seeley DG, Kelsey J, Jergas M, Nevitt MC. Predictors of ankle and foot fractures in older
women. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1996;
11:1347.
8. Simon, RR, Koenigsknecht, SJ. Fractures of the Ankle. In: Emergency Orthopedics: The Ex
tremities, McGraw-Hill, New York 2001. p.497.
9. Michelson JD. Fractures about the ankle. J Bone Joint Surg Am 1995; 77:142.
10. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. The ability of the Lauge-Hansen
classification to predict ligament injury and mechanism in ankle fractures: an MRI study.
J Orthop Trauma 2006; 20:267.
11. Michelson J, Solocoff D, Waldman B, et al. Ankle fractures. The Lauge-Hansen
classification revisited. Clin Orthop Relat Res 1997; :198.
12. Carr, JB. Malleolar fractures and soft tissue injuries of the ankle. In: Skeletal trauma: Basi
c science, management and reconstruction, 3rd edition, Browner, BD, Jupiter, JB, Levine,
AM, Trafton, PG (Eds), Saunders, Philadelphia 2003. p.2326.
13. Odak S, Ahluwalia R, Unnikrishnan P, et al. Management of Posterior Malleolar

Fractures: A Systematic Review. J Foot Ankle Surg 2016; 55:140.
14. Markert RJ, Walley ME, Guttman TG, Mehta R. A pooled analysis of the Ottawa ankle
rules used on adults in the ED. Am J Emerg Med 1998; 16:564.

15. van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the
deltoid ligament in supination external rotation ankle fractures: a systematic review of
the literature. Arch Orthop Trauma Surg 2009; 129:227.
16. Nortunen S, Flinkkilä T, Lantto I, et al. Diagnostic accuracy of the gravity stress test and
clinical signs in cases of isolated supination-external rotation-type lateral malleolar
fractures. Bone Joint J 2015; 97-B:1126.
17. Chen PY, Wang TG, Wang CL. Ultrasonographic examination of the deltoid ligament in
bimalleolar equivalent fractures. Foot Ankle Int 2008; 29:883.
18. Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg 2013;
21:32.
19. Willett K, Keene DJ, Mistry D, et al. Close Contact Casting vs Surgery for Initial Treatment
of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial. JAMA 2016;
316:1455.
20. Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. Surgical versus
conservative interventions for treating ankle fractures in adults. Cochrane Database
Syst Rev 2012; :CD008470.
21. Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures. Acta Orthop
Scand 1985; 56:103.
22. Kristensen KD, Hansen T. Closed treatment of ankle fractures. Stage II supination-
eversion fractures followed for 20 years. Acta Orthop Scand 1985; 56:107.
23. Pakarinen HJ, Flinkkil TE, Ohtonen PP, Ristiniemi JY. Stability criteria for nonoperative
ankle fracture management. Foot Ankle Int 2011; 32:141.
24. van den Berg C, Haak T, Weil NL, Hoogendoorn JM. Functional bracing treatment for
stable type B ankle fractures. Injury 2018; 49:1607.
25. Kearney R, McKeown R, Parsons H, et al. Use of cast immobilisation versus removable
brace in adults with an ankle fracture: multicentre randomised controlled trial. BMJ
2021; 374:n1506.
26. Kortekangas T, Haapasalo H, Flinkkilä T, et al. Three week versus six week
immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-
inferiority clinical trial. BMJ 2019; 364:k5432.
27. Moseley AM, Beckenkamp PR, Haas M, et al. Rehabilitation After Immobilization for
Ankle Fracture: The EXACT Randomized Clinical Trial. JAMA 2015; 314:1376.
28. Lin CW, Donkers NA, Refshauge KM, et al. Rehabilitation for ankle fractures in adults.
Cochrane Database Syst Rev 2012; 11:CD005595.
29. Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J
Bone Joint Surg Am 2008; 90:1570.

30. SooHoo NF, Krenek L, Eagan MJ, et al. Complication rates following open reduction and
internal fixation of ankle fractures. J Bone Joint Surg Am 2009; 91:1042.
31. Grewal K, Atzema CL, Sutradhar R, et al. Venous Thromboembolism in Patients
Discharged From the Emergency Department With Ankle Fractures: A Population-Based
Cohort Study. Ann Emerg Med 2022; 79:35.
32. Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: initial and long-
term outcomes. Foot Ankle Int 2008; 29:1184.
33. Davidovitch RI, Walsh M, Spitzer A, Egol KA. Functional outcome after operatively
treated ankle fractures in the elderly. Foot Ankle Int 2009; 30:728.
Topic 227 Version 34.0

GRAPHICS
Skeletal structure of the leg, ankle, and foot: Medial view
Reproduced with permission from: Cael C. Leg, ankle, foot. In: Functional Anatomy: Muscoloskeletal Anatomy, Kinesiology, and Pa
Lippincott Williams & Wilkins, Philadelphia 2010. Copyright © 2010 Lippincott Williams & Wilkins. www.lww.com.
Graphic 94921 Version 5.0

Skeletal structure of the leg, ankle, and foot: Lateral view
Reproduced with permission from: Cael C. Leg, ankle, foot. In: Functional Anatomy: Muscoloskeletal Anatomy, Kinesiology, and Pa
Therapists. Lippincott Williams & Wilkins, Philadelphia 2010. Copyright © 2010 Lippincott Williams & Wilkins. www.lww.com.

Sectional anatomy of ankle region
The orientation drawing depicts the structures visible in the MRI of the ankle.
MRI: magnetic resonance image.
Reproduced with permission from: Lower limb. In: Clinically Oriented Anatomy, 7th ed, Moore KL, Dalley AF, Agur A (Eds), Lippinco
Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Lateral ankle ligaments
ATFL: anterior talofibular ligament; PTFL: posterior talofibular ligament; CFL:

calcaneofibular ligament.

Medial ankle ligaments
The deltoid ligament, located on the medial side of the ankle, is a

broad band of connective tissue that has four separate divisions
connecting the distal tibia with the talus, calcaneus, and the
navicular bones.

Tendons and ligaments on medial aspect of ankle and foot
(A) The relationships of the flexor tendons to the medial malleolus and
sustentaculum tali are shown as they descend the posterolateral aspect of the
ankle region and enter the foot. Except for the part tethering the flexor hallucis
longus tendon, the flexor retinaculum has been removed.
(B) The four parts of the medial (deltoid) ligament of the ankle are demonstrated in
this dissection.
* Talonavicular ligament.
Reproduced with permission from: Lower limb. In: Clinically Oriented Anatomy, 7th ed, Moore KL,
Dalley AF, Agur A (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott
Williams & Wilkins. www.lww.com.

Syndesmosis (interosseous ligament)
Anterior view of the tibia and fibula. The interosseous ligament is a

thick osseofascial membrane that runs the length of the tibia and
fibula and terminates distally in the thicker syndesmosis.

Tarsal tunnel anatomy
The tarsal tunnel syndrome is caused by entrapment of the posterior tibial nerve beneath the flexor retin
on the medial side of the ankle. Entrapment may also include the two branches, the medial and lateral p
nerves. Note that the bifurcation of the tibial nerve, which is depicted occurring proximal to the retinacu
the diagram above, can occur more distally in the region of the retinaculum.
Reproduced with permission from: Moshrefi S, Curtin C. Nerve repair and reconstruction—Tibial nerve. In: Operative Techniques i
Surgery, Chung KC (Ed), Wolters Kluwer, Philadelphia 2020. Copyright © 2020 Wolters Kluwer Health.

Lateral malleolus definition
There is no single, widely accepted definition of the anatomic

margins of the lateral malleolus. For the purpose of this review, the
lateral malleolus refers to the distal part of the fibula that articulates
with the talus and distal tibia. Lateral malleolar fractures lie between
the distal tip of the fibula (inferior yellow line) and the most proximal
portion of the fibula that lies directly adjacent to the tibia in the tibial
groove (superior yellow line).
Courtesy of Patrice Eiff, MD.

Ring scheme for ankle fractures
The ankle can be conceived of as a ring of supporting structures surrounding the

talus (picture A). If the ring is broken at one site (picture B), the injury is stable and
can generally be managed nonoperatively. If the ring is broken at two or more
sites (picture C), the injury is unstable and is managed operatively. Fractures or
ligament ruptures constitute breaks in the ring.

Pilon fracture of the distal tibia on radiography and CT
An A-P (A) and lateral radiograph (B) of the ankle show a tibial fracture (arrow) involving the tibio-talar jo
(arrow) associated with a spiral fracture of the fibula (arrowhead). Image C is a CT reconstructed in the sa
plain showing the tibial fracture (arrow).
A-P: anteroposterior; CT: computed tomography.

Ottawa Ankle Rules
Ankle films: A series of ankle radiograph films is required only if

there is any pain in malleolar zone and any of these findings: bone
tenderness at A; bone tenderness at B; inability to bear weight both
immediately and in the emergency department.
Foot films: A series of foot radiograph films is required only if there

is any pain in midfoot zone and any of these findings: bone
tenderness at C; bone tenderness at D; inability to bear weight both
immediately and in the emergency department.
Modified from: Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the
Ottawa Ankle Rules. JAMA 1994; 271:827.

Normal mortise view
The mortise view enables assessment for fractures and spacing of

the entire joint surface, including that between the fibula and talus.
The distance between the talus and either the fibula or tibia should
be equal throughout the joint.

Oblique uncomplicated fracture of the lateral malleolus
The fracture is best seen on the lateral view (arrow). The anteroposterior (AP) x-
ray demonstrates the symmetry of the joint: the distance between the superior
aspect of the medial malleolus and the talus is equal to the distance between the
tibial plafond and the talus (arrowheads). This relationship must be confirmed on
the mortise view. Provided there is no injury to the deltoid ligament, this is a
stable injury and surgical intervention is not needed.
Courtesy of Jari Salo, MD.

Isolated fracture of the medial malleolus
A fracture of the medial malleolus (white arrow) is clearly seen on

this view. Care must be taken to exclude additional injuries (eg,
proximal fibular fracture) commonly associated with fractures of the
medial or posterior malleoli.
Courtesy of Scott M Koehler, MD.

Lateral projection of the ankle
Major landmarks of the ankle are found in the lateral plain radiograph above.

Oblique fractures of the lateral and posterior malleoli
While the fracture of the lateral malleolus (arrow) is clearly seen on both views,
the posterior malleolar fracture (arrowhead) is only seen on the lateral view. This
combination of injuries is unstable and requires orthopedic referral regardless of
whether widening of the medial joint line (dashed arrow) is apparent.
AP: anterior posterior.

Bimalleolar fracture
Fractures of the medial malleolus (white arrow) and lateral malleolus (blue
arrow) are visible on both views. Although spacing in the mortise view
appears normal, this is an unstable injury and requires orthopedic referral.

Unstable lateral malleolar fracture
In addition to the displaced, oblique fracture of the lateral malleolus (black

arrows), widening of the medial joint space (white arrow), indicating ligament
disruption, is also evident on this x-ray. This unstable injury requires surgical
fixation.

Gravity stress mortise radiograph of the ankle
These photographs show the position for obtaining a gravity stress

mortise view of the ankle. This view can demonstrate injury of the
medial ankle ligaments and can be obtained without inflicting
unnecessary pain on the patient, as occurs with a manual stress
view.
Courtesy of Scott Koehler, MD.

MRI showing osteochondral injury of the talus
This MRI scan demonstrates an osteochondral injury of the talus

(arrow).
MRI: magnetic resonance imaging.

Bone scan showing a stress fracture of the distal

fibula
A bone scan shows increased activity in the distal right fibula

(arrow).

Fibula fracture above the lateral malleolus
This fracture is above the joint line and involves disruption of the
syndesmosis. Such injuries require orthopedic referral.

Fibula fracture above lateral malleolus: Lateral

view
This lateral plain radiograph shows an oblique fracture (arrow)

through the distal fibula.

Fibula fracture above lateral malleolus: Mortise

view
A fibula fracture (arrow) above the joint line is seen on this Mortise
view of the ankle.

Avulsion fracture of the lateral malleolus
Seen on this x-ray is a transverse avulsion fracture of the lateral

malleolus (yellow arrow) distal to the joint line. The fracture
fragment is larger than those typically associated with an avulsion
fracture, suggesting the possibility of additional injuries and ankle
instability.

Lateral malleolar fracture
This nondisplaced, oblique fracture of the lateral malleolus (white arrow) was
stable and managed nonoperatively, once the absence of a medial injury was
confirmed.

Trimalleolar fracture
An oblique fracture of the lateral malleolus (arrow on AP and lateral x-rays)

proximal to the joint, in addition to fractures of the medial malleolus (arrowhead
on AP view) and posterior malleolus (dashed arrow on lateral view), are seen
here. Note how the posterior malleolar fracture and the displacement of the
fibular fracture can only be seen on the lateral view. The diastasis between the
tibia and fibula reflects a syndesmotic injury. The highly unstable nature of
trimalleolar fractures is reflected in the loss of joint congruence and the
abnormal increased width between the medial malleolus and the talus.

Osteoarthritis following ankle fracture
Ankle osteoarthritis developed in this 41-year-old male after an

ankle injury with ligamentous damage and distal fibular fracture.
Callus at the distal fibular fracture site, several centimeters above
the joint line (upper arrow), and medial joint line narrowing with
sclerotic changes (lower arrow), suggestive of osteoarthritis, can be
seen.

Ankle fracture complicated by complex regional

pain syndrome
Early Complex Regional Pain Syndrome (CRPS) in a patient with a

lateral avulsion fracture. The patient had been treated with weight
bearing as tolerated in a walking cast boot. The patient presented
with increased pain, swelling, warmth, and skin changes 23 days
after the injury. He responded to gabapentin, early motion, tactile
stimulation and sympathetic nerve blockade.

Ankle fracture after resolution of complex regional

pain syndrome
CRPS, 28 days after injury. The patient responded to gabapentin,

early motion, tactile stimulation, and lumbar sympathetic nerve
block. This photo (taken four days after a lumbar sympathetic nerve
block and five days after the photo "Ankle fracture complicated by
complex regional pain syndrome") shows improvement in the
swelling and skin changes. The patient recovered fully after three
months of treatment.

Contributor Disclosures
Scott M Koehler, MD No relevant financial relationship(s) with ineligible companies to disclose. Chad
A Asplund, MD, MPH, FAMSSM No relevant financial relationship(s) with ineligible companies to
disclose. Matthew Gammons, MD No relevant financial relationship(s) with ineligible companies to
disclose. Jonathan Grayzel, MD, FAAEM No relevant financial relationship(s) with ineligible companies
to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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EPIDEMIOLOGY AND RISK FACTORS

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Malleolar fractures — Isolated malleolar fractures tend to be stable if they are

CLINICAL PRESENTATION AND EXAMINATION

Emergency conditions, such as an open fracture, neurovascular compromise, or fracture

● Site of the most significant pain

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Clinicians should inspect the injured ankle for:

The amount of swelling is not a reliable guide to the presence of a fracture.

● It is isolated to the lateral, medial, or posterior malleolus

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If a fracture of the talus is suspected, or if significant comminution is present, a CT scan will

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL

Initial treatment — Emergency conditions, such as an open fracture or neurovascular

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Clinicians should instruct the patient to call immediately for:

● Pain that is severe or increasing

Patients awaiting orthopedic consultation or surgery should remain nonweightbearing in a

Management of specific malleolar fractures — There is little high quality evidence to

Lateral malleolar fractures — Fracture stability determines treatment. The location of an

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Instability is demonstrated by 2 mm or more of displacement of the fibular fracture, an

Isolated medial or posterior malleolar fractures — Care must be taken with these

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Bimalleolar and trimalleolar fractures — These fractures are unstable and require

REHABILITATION AFTER ANKLE FRACTURE

A systematic review of 38 controlled trials related to the rehabilitation of ankle fractures

● Early performance of ankle exercises following surgical fixation improved ankle

● Neither stretching nor manual therapy (passive motion exercises performed by a

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Acute complications of ankle fractures, such as injuries to peripheral nerves or vascular

Venous thromboembolism (VTE) is an infrequent complication, particularly of fractures

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Nonunion or malunion of ankle fractures is uncommon in healthy patients. Nevertheless,

● (See "General principles of fracture management: Bone healing and fracture

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● (See "General principles of acute fracture management".)

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

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• It is isolated to the lateral, medial, or posterior malleolus

● Management – Unstable ankle fractures often require surgical repair. Management of

Use of UpToDate is subject to the Terms of Use.

4. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?

13. Odak S, Ahluwalia R, Unnikrishnan P, et al. Management of Posterior Malleolar

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Skeletal structure of the leg, ankle, and foot: Medial view

Graphic 94921 Version 5.0

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Skeletal structure of the leg, ankle, and foot: Lateral view

Graphic 94922 Version 4.0

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Sectional anatomy of ankle region

MRI: magnetic resonance image.

Graphic 93194 Version 5.0