Common questions about ankle fractures

An ankle fracture can significantly impact your mobility and daily activities, making it essential to understand the nature of this injury and how it is treated. Whether caused by a fall, a sports accident, or another type of trauma, prompt diagnosis and proper care are key to a smooth recovery. We speak to a leading orthopaedic surgeon Professor Lyndon Mason, who explores common questions about ankle fractures, including their symptoms, diagnosis, and treatment options.

What are ankle fractures?

An ankle fracture is a break in one or more of the bones that make up the ankle joint. This joint consists of three primary bones:

• Tibia (shinbone)
• Fibula (the smaller bone alongside the tibia)
• Talus (the bone between the tibia and heel)

Ankle fractures can range from small cracks to severe breaks involving multiple bones and the surrounding ligaments that stabilize the joint. These injuries typically result from trauma, such as falls, sports injuries, or road traffic collisions. Early recognition of symptoms is essential to ensure timely treatment and proper healing.
 

The role of ankle stability

Ankle stability depends on the integrity of the bones, ligaments, and soft tissues that support the joint. The key stabilising structures include:

• Medial and lateral ligaments – These ligaments prevent excessive movement and help maintain alignment.
• Syndesmosis – A group of ligaments that connect the tibia and fibula, essential for joint stability.
• Articular surfaces – The way the bones fit together (like a key in a lock) affects weight distribution and stability.

When an ankle fracture disrupts these stabilizing structures, the joint may become unstable, increasing the risk of long-term complications such as arthritis, chronic pain, or recurrent instability. Treatment, whether non-surgical or surgical, aims to restore stability and function to prevent these issues.

What are the symptoms of an ankle fracture?

The most common symptom of an ankle fracture is pain, which may be severe and worsen with movement or when bearing weight. Additional signs include:

• Swelling – Often develops rapidly around the ankle.
• Bruising – Discoloration due to bleeding under the skin.
• Deformity – In cases where the bones are displaced, the ankle may appear misshapen.
• Inability to bear weight – Severe fractures may make it impossible to stand or walk.
• Numbness or tingling – This may indicate nerve involvement in the injury.

It's important to note that not all ankle injuries are fractures. Sprains can present with similar symptoms, but a medical professional will perform an evaluation, which may include X-rays, to confirm the diagnosis.

How is an ankle fractured diagnosed?

If an ankle fracture is suspected, it is important to seek medical attention promptly. A doctor will begin with a physical examination, assessing:

• Swelling and bruising
• Tenderness over specific bony areas
• Deformity or instability
• Ability to bear weight

Use of the Ottawa Ankle Rules

To determine whether an X-ray is necessary, doctors often use the Ottawa Ankle Rules. An X-ray is recommended if there is pain in the ankle and any of the following:

• Tenderness over the lateral malleolus (outer ankle bone) or medial malleolus (inner ankle bone).
• Inability to bear weight immediately after the injury and for four steps in the clinic or emergency department.

For midfoot injuries, an X-ray is indicated if there is pain and:

• Tenderness at the base of the fifth metatarsal (outer foot).
• Tenderness over the navicular bone (inner midfoot).
• Inability to bear weight for four steps.

Advanced imaging

If the fracture is complex or X-rays do not provide enough detail, additional imaging may be needed:

• CT scan – Provides a more detailed view of bone alignment, especially in fractures involving the joint surface.
• MRI scan – Useful for assessing ligament injuries, cartilage damage, or occult fractures that may not be visible on X-ray.

Early and accurate diagnosis is crucial for determining the appropriate treatment and ensuring optimal recovery. 

What are the treatment options for ankle fractures?

Treatment for ankle fractures depends on the type and severity of the injury. The goal is to restore and maintain stability and alignment of the ankle joint to optimize functional recovery and reduce the risk of post-traumatic arthritis.

Non-surgical treatment

Stable fractures that do not compromise the alignment of the ankle mortise can often be managed without surgery. According to the BOAST (British Orthopaedic Association Standards for Trauma) guidelines, non-surgical treatment includes:

• Analgesia and Immobilisation – Stable fractures can be treated with a splint or cast.
• Weight-bearing as tolerated – Most patients with stable fractures can bear weight immediately.
• Follow-up – If there is uncertainty about stability, patients should be reviewed within two weeks with repeat weight-bearing radiographs to confirm alignment.
• Close Contact Casting (in older patients) – In patients over 60, if a reduction is maintained, a close contact cast is an alternative to surgery.

Surgical treatment

Surgery is usually required for unstable fractures. BOAST guidelines recommend:

• Early fixation – For unstable fractures, surgery should ideally be performed on the day of injury or the following day.
• Surgical goals – The primary objective is to restore ankle mortise alignment and stability. The syndesmosis should be assessed and stabilized if unstable.
• Fixation methods – This often involves metal plates and screws to hold the bones in place during healing.
• External fixation (rare cases) – In severe injuries with soft tissue compromise, temporary external fixation may be required.
• Postoperative weight-bearing – Most patients can bear weight as tolerated unless there are concerns about stability, neuropathy, or soft tissue status.

Rehabilitation and follow-up

• Fracture Clinic Review – After surgery, patients should be reviewed within six weeks to assess healing and detect complications.
• Thromboprophylaxis – Patients should be assessed for clot prevention based on local protocols.
• Patient Education – Patients should receive guidance on recovery, rehabilitation, and return to activities such as work and driving. A self-referral mechanism should be available for those whose progress is not as expected.

By following these guidelines, treatment aims to achieve optimal outcomes while minimising complications and long-term dysfunction.

How can I prevent complications?

Preventing complications following an ankle fracture requires careful adherence to the treatment plan, lifestyle modifications, and medical follow-up. The key areas to focus on include:

1. Follow medical advice and rehabilitation

• Attend all follow-up appointments – This ensures proper monitoring of healing and early identification of complications.
• Adhere to weight-bearing guidelines – Although most can weight-bear early, it is important to follow recommendations from your treating doctor.
• Perform recommended exercises – Rehabilitation focuses on restoring strength, flexibility, and balance to prevent stiffness and long-term dysfunction.

2. Manage modifiable risk factors

• Quit smoking – Smoking reduces blood supply to bones and soft tissues, leading to delayed healing, increased infection rates, and a higher risk of the bones not healing​.
• Control diabetes – Poorly controlled diabetes is associated with higher infection rates, wound complications, fixation failure, and even amputation​. Strict blood sugar control and close monitoring are essential.
• Maintain good nutrition – A diet rich in calcium, vitamin D, and protein supports bone healing.

3. Prevent and monitor for infections

• Keep the wound clean and dry – Proper post-operative wound care minimises the risk of infections.
• Watch for warning signs – Symptoms such as increased redness, swelling, warmth, or discharge should prompt immediate medical attention.

4. Reduce the risk of thrombosis (Blood clots)

• Early mobilisation – Moving the toes, ankle, and leg as soon as medically allowed reduces the risk of deep vein thrombosis (DVT).
• Use blood thinners if advised – If you have additional risk factors (obesity, prolonged immobilization, prior DVT), your doctor may recommend anticoagulants (e.g., heparin or aspirin)​.

5. Seek medical attention for any concerns

Early intervention is key. If you experience severe pain, persistent swelling, numbness, or difficulty moving your foot, consult your doctor promptly. Delayed diagnosis and treatment can lead to complications such as post-traumatic arthritis and long-term disability​.

By proactively managing risk factors and following medical recommendations, you can significantly reduce the likelihood of complications and improve overall recovery outcomes.