Ankle Sprains and Fractures
Richard A. Zell, M.D.
Ankle injuries can occur in the workplace. Two common injuries include: ankle sprains, and ankle fractures.
The bones that make up the ankle include: the Tibia, Fibula and Talus. The bones of the ankle joint are stabilized by ligaments. These include the medial or inside ligaments (Deltoid ligament) and the outside or lateral ligaments. There are also ligaments that connect the Fibula and Tibia above the ankle called Syndesmotic ligaments. Ankle sprains are injuries to these ligaments. They occur after inversion (the ankle rolling in) or twisting injuries. Sprains typically involve the lateral ligaments but can also involve the Syndesmotic or Deltoid ligament. Injuries to the Syndesmtoic ligaments are called high ankle sprains and are common injuries in football players but can also occur in the workplace. There are three grades of ankle sprains (1-3) that describe a progression from a stretch injury to complete disruption of the ligaments.
Treatment of ankle sprains typically involves RICE (rest, ice, compression and elevation). Lower grade sprains are managed with an ankle brace/Aircast while higher grade sprains are managed in a walking or CAM boot. The CAM walker allows the patient to weight bear without the ankle having to move and become more inflamed. Patients are allowed to weight bear as tolerated with assist of crutches as required. Physical therapy is helpful in the recovery of ankle sprains. PT is not started initially in order to allow the swelling/inflammation to decrease.
The great majority of lateral ankle sprains can be managed without surgery. Studies have shown that even with complete disruption/tearing of the ligaments, patients do better with non-operative treatment rather than surgery to repair the ligaments. There are some exceptions where surgery is required such as patients that have an ankle sprain associated with a bone chip or osteochondral defect. These patients require an ankle arthroscopy to remove/repair the bone fragment. At times, injuries to the ligaments above the ankle (Syndesmotic ligaments) can be associated with a shift of the bones of the ankle and this injury also requires surgery. Some patients may have continued or chronic symptoms several months after an ankle sprain and may require surgery to tighten the lateral ligaments if they are loose (Brostrom procedure). Other patients have continued inflammation/scarring after a sprain and may require an ankle arthroscopy and debridement.
The amount of time out of work following an ankle sprain depends on the grade of the injury and the patient’s job. Grade I sprains typically heal in approximately 2-3 weeks. Grade III sprains can take 6-8 weeks or longer to fully heal. Patients with ankle sprains can typically be sent back to work on modified duty as the treatment of ankle sprains typically allows weight bearing to tolerance with a brace or boot. Patients will likely need time off for physical therapy and allowances may be required for use of a brace/limited walking. Patients with jobs that include working on unprotected heights/ladders/etc. may not be able to return to full duty for several weeks. 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 thathave 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 pre-fracture 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 accommodations 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.