Any deformity, malalignment, edema, ecchymosis, or erythema should be noted. Physical ExaminationĮxamination should begin with gross visual inspection. Additional areas include past fractures or stress fractures as well as if there are any disorders of bone health. Competition level (if participating in athletics) as well as associated symptoms such as weightbearing status, paresthesias, or cold feet/loss of distal pulses should also be noted. The activity, mechanism, and timing of injury should be noted as this can help target areas for more thorough physical examination and tailor treatment. Suspicion for injury to the talus and more distal structures, such as the navicular and fifth metatarsal base, is also warranted. Structures in proximity to the ankle joint can potentially be associated with malleolar fractures, including the deep peroneal nerve, tibial nerve, and both anterior and posterior tibial arteries. According to original research, the most common mechanisms included supination-external rotation fractures accounting for 40–75% of ankle fractures supination-adduction for 10–20% pronation-abduction for 5–21% and pronation-external rotation for 7–19%. If external rotation of the talus is added, syndesmotic injury and proximal fibula fractures (e.g. The addition of an axial compression force to the everted ankle can injure the posterior malleolus. Again, if the force continues, the talus will shift laterally and impact the lateral malleolus, causing an oblique fracture. The medial malleolus is implicated in an eversion position and an abduction force, stressing the deltoid ligament complex and potentially leading to a medial malleolus avulsion fracture. If the twisting force continues, the talus may shift and impact the medial malleolus, causing an oblique fracture. If forceful enough, this may avulse the lateral malleolus. The lateral malleolus is implicated with an inversion position and an adduction force, which stresses the lateral ligaments. Depending on the position of the foot and the direction of the twisting force, one or more of these ligaments and malleoli can be injured. This complex articulates with the talus and is supported by a complex network of ligaments, effectively forming a “ring” around the talocrural joint. The trimalleolar complex is comprised of the medial, lateral, and posterior malleoli. 9 Using the OA/OTA fracture classification, type B fractures comprise the greatest percentage of ankle fractures, followed by Type A and Type C. 1 Traumatic medial malleolar fractures have the highest proportion of open injuries. 41 Amongst ankle fractures, unimalleolar injuries occur most commonly (60-70% lateral > medial), 41 followed by bimalleolar (15-20%), and trimalleolar (7-12%) respectively. 41,42 Female incidence increases between the ages of 30-39 and 60-69, while the male incidence either follows a more uniform distribution 42 or decline after the age of 20. 5 Mean patient age, depending on the study, ranges from the 40’s to 50’s, with an overall female predominance. 7 The incidence in the adult population is dependent upon multiple factors, including age, sex, specific sport, and competitive level in athletics. EpidemiologyĪnkle fractures account for 9.3% of all fractures, 6 over 50% of traumatic foot and ankle fractures, 9 and are the 4 th most common fracture in the elderly. 4 Additional classification systems include Danis-Weber and OA/OTA (please see supplemental assessment). 3 Similarly, a recent small study found that the mechanisms proposed by Lauge-Hansen were only 58% accurate in predicting actual fracture patterns. 2 However, one report found that nearly 53% of the ankle injuries studied did not coincide with the predicted injury pattern based on mechanism of injury, and that 14% had a common fracture pattern not explained by the various combination of forces proposed by Lauge-Hansen. The Lauge-Hansen classification system for ankle fractures attempts to link mechanism of injury and fracture pattern. ![]() 1 However, the exact combination of forces that produce a particular pattern of fracture is still not clear. Such movements almost always include inversion or eversion. EtiologyĪnkle fractures typically result from a sudden, forceful twisting movement in multiple planes. ![]() ![]() Pediatric ankle fractures typically involve the physis and are not within the scope of this article. Information on ligament injuries and ankle sprains may be found in “ Ankle Sprain”. Information on foot and ankle stress fractures and other overuse injuries can be found in “ Ankle and Foot Overuse Disorders”. This article will focus strictly on fractures of distal tibia and fibula in the adult patient. Ankle fractures refer to any fracture involving the bones of the talocrural joint, namely the distal aspects of the tibia and fibula, and the talus.
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