By Richard A. Zell, M.D.
Ankle fractures can also occur after twisting injuries and can also be caused by other traumatic events such as falls or motor vehicle accidents. The fracture or ‘break’ can involve the Fibula and/or the Tibia. Fractures of the Talus will not be discussed in this review. Ankle fractures typically occur in characteristic patterns depending on the position of the foot/mechanism of injury. Some fractures can occur without disruption of the ankle joint/ displacement of the bones (non-displaced fractures) while other injuries lead to gross shifting of the facture fragments/alignment of the joint.
Some ankle fractures can be treated without surgery if the bony fragments are in overall good alignment. These patients can be managed in a cast or possibly a removable boot or Cam walker. There are other patients that have a minimally displaced fracture and traditionally it was difficult to determine the proper treatment for these patients (casting or surgery). It has been found that special radiographic tests called stress views can help determine which patients require surgery.
Displaced ankle fractures typically require surgery. The goal of ORIF (open reduction internal fixation) is to return the bones of the ankle to their anatomic or prefracture position and then the bone fragments are held in position with plates screws or other metal implants.
Recovery from ankle ORIF includes initial immobilization in a splint (placed in the operating room). Patients require narcotic medication initially and a daily Aspirin (to decrease the risk of DVT). Sutures are typically removed at two weeks s/p surgery and the patient is placed in a cast or a removable boot. This boot may be removed several times per day to allow the patient to perform gentle range of motion exercises. Patients are kept non weight bearing for at least 6 weeks s/p surgery. Crutches or a knee walker are required. Once the fracture has healed adequately (usually at 6 weeks s/p surgery) the patient may start weight bearing in a cast boot and eventually transition into a sneaker. Physical therapy is started when the cast is removed. Many patients also require a course of work conditioning.
Risks of surgery include infection, wound healing problems, and local nerve injury. These risks can lead to a less optimal result. In order to avoid these risks, patients are encouraged to stop smoking before surgery to decrease the risk of wound healing problems or infection. Wound healing difficulties can also be avoided by waiting until the swelling is decreased before proceeding with ORIF.
Time out of work after ankle fracture again depends on the severity of the injury. Most ankle fractures require non weight-bearing for at least 6 weeks. This is followed by 6 weeks of rehab to allow return of strength and motion. The pain and swelling from injury typically prevents work over the initial 7-10 days after injury. For patients with a non-displaced fracture, return to modified duty is possible after 10 days with accomodations for their NWB status and use of a cast or brace. Patients requiring surgery may not be able to return to modified duty until at least 3-4 weeks after surgery. The return to full duty status after ankle ORIF can be prolonged (6 months of longer) for patients who perform heavy work such as laborers or construction workers.