Ankle Fracture

An ankle fracture can involve the lateral malleolus, medial malleolus, posterior malleolus or combinations of these structures with associated deltoid and syndesmotic ligament injury.

The treatment question is not simply whether a malleolus is fractured. The key question is:

Is the talus stable and anatomically centred within the ankle mortise?

Loss of even small degrees of talar alignment substantially alters ankle contact mechanics.

Danis Weber classification

Classifies the fibular fracture according to its relationship to the distal tibiofibular syndesmosis.

Weber A

Fibular fracture below the syndesmosis.

Usually stable if the medial structures are intact.

Often corresponds to supination adduction injury.

Weber B

Fibular fracture at the level of the syndesmosis.

Syndesmotic stability varies.

Commonly corresponds to supination external rotation.

Weber C

Fibular fracture above the syndesmosis.

Strongly associated with syndesmotic disruption and an unstable ankle.

A very proximal Weber C fracture associated with syndesmotic and medial injury is a Maisonneuve fracture.

Palpate the entire fibula in every apparently isolated medial ankle injury.

Lauge Hansen classification

Describes foot position followed by direction of deforming force.

Supination external rotation

Most common pattern.

Stage 1:

Anterior inferior tibiofibular ligament injury.

Stage 2:

Oblique spiral distal fibular fracture at the syndesmosis.

Stage 3:

Posterior inferior tibiofibular ligament rupture or posterior malleolar fracture.

Stage 4:

Medial malleolar fracture or deltoid ligament rupture.

Supination adduction

Stage 1:

Distal fibular avulsion or transverse infrasyndesmotic fracture.

Stage 2:

Vertical medial malleolar fracture, often with medial plafond impaction.

Pronation external rotation

Stage 1:

Medial malleolar fracture or deltoid disruption.

Stage 2:

Anterior syndesmotic injury.

Stage 3:

Spiral fibular fracture above the syndesmosis.

Stage 4:

Posterior syndesmotic injury or posterior malleolar fracture.

Pronation abduction

Stage 1:

Medial malleolar fracture or deltoid disruption.

Stage 2:

Syndesmotic injury.

Stage 3:

Transverse or comminuted suprasyndesmotic fibular fracture.

The mechanism classification is useful for understanding injury sequence, but it does not predict every ligament injury reliably.

Patients present with ankle pain, swelling and inability or difficulty bearing weight.

Inspect for:

Gross dislocation
Open wound
Skin tenting over the medial malleolus
Fracture blisters
Medial tenderness
Proximal fibular tenderness

Document:

Dorsalis pedis and posterior tibial pulse
Superficial peroneal sensation
Deep peroneal sensation
Tibial nerve sensation
Motor function where pain permits

An ankle fracture dislocation can rapidly threaten medial skin and requires immediate reduction.

Obtain:

AP
Mortise
Lateral ankle radiographs

The mortise view is obtained with approximately 15° internal rotation and allows assessment of talar centring.

Obtain full length tibia and fibula imaging when:

Proximal fibula is tender
Medial injury exists without obvious distal fibular fracture
Maisonneuve injury is possible

CT: obtain for:

Posterior malleolar fracture
Trimalleolar fracture
Pilon overlap
Complex articular injury
Preoperative planning where posterior fragment morphology changes approach

Stable versus unstable isolated Weber B fractures can be clarified with weight bearing radiographs once pain allows or selected stress imaging.

Medial clear space widening suggests deep deltoid incompetence and talar instability, but interpretation should consider mortise positioning and comparison with the superior clear space.

Emergency reduction

Immediately reduce:

Fracture dislocation
Threatened skin
Neurovascular compromise
Severe talar displacement

Use adequate analgesia or procedural sedation.

After reduction:

Repeat neurovascular examination
Obtain post reduction radiographs
Apply a well moulded splint

Do not leave the ankle in a redislocated position because the splint was inadequately moulded.

Stable fracture

Stable isolated lateral malleolar fractures with a congruent mortise can be managed nonoperatively using a walking boot or functional brace.

Early weight bearing as tolerated is increasingly appropriate in stable injuries.

Repeat imaging is required if stability was initially uncertain.

Unstable fracture

Operative fixation is appropriate for:

Bimalleolar fracture
Bimalleolar equivalent fracture with deltoid incompetence and talar shift
Trimalleolar fracture with instability
Talar displacement
Unstable syndesmotic injury
Displaced medial malleolar fracture causing mortise incongruity
Open fracture
Failure to maintain acceptable reduction

Lateral malleolus

Simple oblique fibular fractures can be treated with lag screw compression plus a neutralisation plate or with an antiglide construct.

Comminuted fibular fractures require restoration of:

Length
Rotation
Alignment

A bridging plate can preserve comminution biology.

Fibular shortening is unacceptable because it permits lateral talar shift.

Medial malleolus

Reduce the articular surface anatomically.

Common fixation uses:

Lag screws
Screw plus antiglide strategy for vertical patterns
Cerclage compression constructs for small fragments

A vertical medial malleolar fracture must be protected against vertical shear rather than treated as a simple transverse avulsion.

Posterior malleolus

The older rule of fixing only fragments involving more than 25% of the articular surface is no longer sufficient.

Fixation should be considered according to:

Articular displacement
Posterior fragment morphology
Involvement of the incisura
Syndesmotic instability
Persistent posterior talar subluxation
Size of the fragment

Direct posterior reduction is increasingly preferred for substantial displaced fragments because it restores both articular congruity and the posterior syndesmotic attachment.

Syndesmosis

After malleolar fixation, assess syndesmotic stability.

Fix an unstable syndesmosis only after the fibula has been restored to correct length and rotation.

Options include:

3.5 or 4.5 mm syndesmotic positioning screw
Flexible suture button construct

A positioning screw should stabilise rather than compress the distal tibiofibular relationship. AO technique places the screw just above the distal tibiofibular joint, parallel to the plafond, with the ankle neutral.

Malreduction of the syndesmosis is a major cause of poor outcome.

Deltoid ligament

Routine deltoid repair is unnecessary when fixation restores a congruent stable mortise.

Explore or repair when:

Medial tissue is interposed and blocks reduction
Persistent medial instability remains despite correct osseous and syndesmotic reconstruction.

Postoperative management

Begin ankle movement once wound condition and fixation stability permit.

Stable anatomically reconstructed fractures can often begin early protected weight bearing, although severe fractures, poor bone quality and syndesmotic constructs may require greater restriction.

Major complications include:

Wound problems
Infection
Syndesmotic malreduction
Fibular shortening
Ankle stiffness
Post traumatic osteoarthritis
Symptomatic hardware
Nonunion, particularly medial malleolus
Chronic instability

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Humeral Shaft Fracture

A humeral shaft fracture involves the diaphysis between the proximal and distal metaphyseal regions.

Unlike weight bearing long bone fractures, many humeral shaft fractures heal successfully with functional bracing because substantial angulation and shortening can be tolerated without major loss of upper limb function.

The radial nerve is intimately related to the posterior humeral shaft in the spiral groove and is the major neurovascular structure at risk.

AO/OTA classification

Humeral shaft fractures are coded 12.

12A: Simple

Spiral
Oblique
Transverse

12B: Wedge

Spiral wedge
Bending wedge
Fragmented wedge

12C: Multifragmentary

Complex spiral
Segmental
Irregular multifragmentary

Fractures are also described according to proximal, middle or distal third location.

Holstein Lewis fracture

A spiral fracture of the distal third of the humeral shaft.

The distal fragment can trap or injure the radial nerve as it pierces the lateral intermuscular septum.

It therefore has a strong anatomical association with radial nerve palsy.

Patients present with arm pain, swelling, deformity and abnormal movement.

Inspect for an open wound.

Document radial nerve function before any manipulation.

Radial nerve motor examination:

Wrist extension
Finger MCP extension
Thumb extension

Radial nerve sensory examination:

Dorsal first web space

Also document median and ulnar nerve function and distal pulses.

Primary radial nerve palsy is commonly a neurapraxia and most closed injuries recover spontaneously.

A new radial nerve palsy after reduction or fixation is more concerning for entrapment or iatrogenic injury.

Nonoperative treatment

Functional bracing remains an appropriate treatment for many closed humeral shaft fractures.

Initial treatment:

Coaptation splint or hanging arm support during acute swelling

Then transition after approximately 7 to 14 days to:

Functional Sarmiento brace

Allow early elbow and shoulder movement.

Commonly accepted alignment tolerances include approximately:

Less than 20° anterior angulation
Less than 30° varus or valgus
Less than 3 cm shortening

The shoulder compensates for modest deformity well.

Monitor serial radiographs.

A fracture that progressively distracts or remains grossly unstable despite bracing requires operative reconsideration.

Operative indications

Strong indications include:

Open fracture requiring debridement and stabilisation
Vascular injury
Floating elbow
Bilateral humeral fractures
Polytrauma requiring dependable mobilisation
Segmental fracture
Pathological fracture
Inability to maintain acceptable alignment
Failure of nonoperative treatment
Symptomatic nonunion

Relative indications include:

Severe obesity or body habitus making bracing ineffective
Large breast tissue preventing brace control
Long spiral fracture with persistent distraction
Need for immediate upper limb weight bearing

Plate fixation

ORIF with plate and screws provides direct reduction and high union rates.

It is particularly useful for:

Distal third fracture
Radial nerve exploration
Segmental pattern
Fracture with vascular injury
Nonunion

Simple fractures can receive compression fixation.

Comminuted fractures can be bridged to preserve biology.

Identify and protect the radial nerve when the surgical approach places it at risk.

Intramedullary nailing

Useful for:

Segmental fracture
Pathological fracture
Severe soft tissue compromise
Selected polytrauma

Potential disadvantages include shoulder pain and rotator cuff injury with antegrade insertion.

Radial nerve palsy

Primary radial nerve palsy accompanying a closed humeral shaft fracture is usually observed initially because spontaneous recovery is common.

Provide:

Wrist extension splint
Hand therapy
Passive range of motion
Serial neurological examination

Recovery often begins with:

Brachioradialis
Radial wrist extensors

then progresses to:

Finger extension
Thumb extension

If there is no clinical recovery, electrodiagnostic testing can be considered around 6 weeks.

If neither clinical nor electrodiagnostic recovery appears by approximately 3 months, nerve exploration and neurolysis should be considered.

Immediate or early radial nerve exploration is appropriate when:

Open fracture
Penetrating injury
Associated vascular injury
Radial nerve function is lost after manipulation or fixation
Nerve transection is suspected
Irreducible fracture suggests nerve interposition
Severe neurogenic pain suggests entrapment.

Do not automatically explore every primary radial nerve palsy in a closed fracture.

Nonunion

Persistent motion, pain and lack of progressive healing require assessment for:

Excessive fracture gap
Instability
Infection
Smoking
Metabolic abnormalities

Aseptic nonunion commonly requires compression plating with debridement of fibrous tissue and bone graft according to biology.

Postoperative management

Encourage early elbow and shoulder motion after stable fixation.

Weight bearing through the arm depends on construct stability and associated injuries.

Major complications include:

Radial nerve palsy
Nonunion
Malunion
Shoulder stiffness
Elbow stiffness
Infection
Iatrogenic nerve injury
Shoulder pain after antegrade nailing

Ankle Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management