Treatment

What treatments should I consider?

Nonsurgical Treatment

In cases where the fracture is stable and not likely to shift further out of position the injury may be treated in a cast. The maneuver to make the bone fragments return to the normal position is called closed reduction. An anesthetic may be needed to reduce the ankle and place the cast.

Once the closed reduction has been performed and the improved position of the fracture fragments confirmed by x-ray, a cast will be applied from toes to just below the knee. If needed the foot will be held over in the position opposite to the direction in which the fracture occurred. The cast may be molded to hold this position. There is usually concern about swelling so the cast is split to allow the limb to swell without causing compression in the tissues.

After a cast has been applied the patient may be mobilized on crutches. It is important to keep the injured foot off the ground and not put any weight on it. When resting, the patient should keep the foot up high to reduce swelling and the throbbing pain that occurs when the leg hangs down.

Movement of the toes is encouraged. This keeps the muscles active, reduces the chance of blood clots in the calf, and helps to prevent adhesion of the tendons.

Follow-up x-rays are usually taken at intervals after the cast has been applied. It is very important to return for follow-up visits and x-rays so that your progress can be assessed.

Casting is usually continued until there are signs of new bone formation on x-ray. Six weeks is the usual cast time for adults. After that the injury may be protected by a walking cast or by a walking splint which can be taken off when the you are not bearing weight.

It usually takes three months for fracture healing to progress enough to allow unprotected weight bearing on the ankle. A period of time to recover strength and mobility may still be needed before the you can return to all normal activities.

It is usually possible to move the fracture fragments back into a good position but there are often some remaining irregularities. The fracture may also shift out of position during the course of cast treatment.

Surgery

The normal ankle is a tight smooth mortise. Irregularities or sloppiness of the ankle joint may cause arthritis in the long run. For this reason it is very common to recommend operative treatment for unstable ankle fractures. The main reason this is offered is because orthopaedic surgeons believe that the results of surgery are better than the results of cast treatment in the long term.

After an operation it is not as necessary to immobilize the ankle. Patients are encouraged to move the ankle as early as possible. This reduces adhesions, helps with blood circulation, and reduction of swelling.

Overall patients recover their function more quickly after surgery. Although the details of the surgery are different for every case the fundamental aim of the operation is to put the broken pieces back in exactly the correct position and hold them there with some form of fixation until they heal. Rigid fixation is desirable because then the joint can be moved without disturbing the fracture fragments. You and your orthopaedic surgeon take all these factors into account before a decision for surgery is made.

When surgery is performed, the fibula is usually fixed by a plate fixed with screws. The fracture of the medial malleolus is held with compression screws. It may actually be difficult to see the fracture lines on x-ray after this type of surgery.

Diastasis, the rupture of the ligaments between the tibia and fibula, should be treated with surgery. One or more screws are passed from the fibula to the tibia holding the bones together for six weeks. The patient should remain non-weight bearing while the injured ligament heals. The screws will fatigue and break eventually so they are normally removed at a second small operation at six weeks.

For Pilon fractures ORIF surgery is also usually recommended (open reduction is surgery to manipulate the broken bones into proper alignment and internal fixation is the placement of hardware such as screws, plates, or rods). Swelling and blistering often make the situation more complicated. External fixation using a frame has been suggested for the early treatment of these fractures with more definitive surgery later after the swelling has recovered.

After surgical treatment the ankle may be splinted for comfort and protection but in other cases early movement is encouraged. If the fixation is strong the ankle can be gently moved without shifting the fracture fragments. Weight bearing is avoided for six weeks or until there are signs of healing on x-ray. Generally speaking once the fracture has healed, recovery of function proceeds rapidly with the help of an exercise program.

After the bone has healed the metal implants serve no further function. In some situations the plate and screws may be uncomfortable and rub against clothing or boots. In about 20 percent of cases this prompts a small secondary operation to remove the implants.