Diseases & Conditions
Ankle Fractures (Broken Ankle)
A broken ankle is also known as an ankle fracture. This means that one or more of the bones that make up the ankle joint are broken.
A fractured ankle can range from:
- A simple break in one bone, which may not stop you from walking, to
- Several fractures, which may require surgery. These types of fractures can be very disabling. In some cases, you may not be able to put weight on your ankle for a few months, affecting your ability to walk, drive, play sports, and work.
Although ankle fractures can occur in people of all ages, they typically happen more often in adults; in fact, they are the fourth most common type of fracture in adults.
Anatomy
Three bones make up the ankle joint:
- Tibia — the shinbone
- Fibula — the smaller bone of the lower leg
- Talus — the small bone that sits between the heel bone (calcaneus) and the tibia and fibula
The tibia and fibula have specific parts that make up the ankle:
- Medial malleolus — the small prominent bone on the inner side of the ankle at the end of the tibia
- Posterior malleolus — the back part of the tibia
- Lateral malleolus — the prominent bone on the outer side of the ankle at the end of the fibula
Doctors classify ankle fractures according to the area of the bone that is broken. For example, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both the tibia and fibular are broken, it is called a bimalleolar fracture.
Two joints are involved in ankle fractures:
- Ankle joint — where the tibia, fibula, and talus meet
- Syndesmosis joint — the joint between the tibia and fibula, which is held together by ligaments
Description
Ankle fractures can be classified by how much the pieces of bone have moved out of their normal position.
Nondisplaced fracture. A nondisplaced ankle fracture is where the bones are not out of place. These fractures do not require surgery.
Displaced fracture. A displaced ankle fracture is where the broken bone fragments are separated. There may be breaks in one, two, or three areas, and the ankle joint may also be dislocated. Most ankle fractures with dislocations require surgical treatment.
Open fracture. When the broken bones break through the skin, the injury is called an open or compound fracture. An open fracture is an emergency and should be treated surgically as soon as possible. This is because an open wound allows outside material, dirt, and debris to contaminate the fracture, increasing the risk of infection.
Cause
Many types of injuries can cause an ankle fracture. They include:
- Twisting, rotating, or rolling your ankle while walking or running
- Tripping or falling from a height, such as a fall from a ladder
- Impact during a car accident
Symptoms
Common symptoms of a broken ankle include:
- Immediate and severe pain
- Swelling
- Bruising
- Tenderness to touch
- Inability to put any weight on the injured foot
- Deformity, especially if the ankle joint is also dislocated
- Numbness and coolness in the foot (in some cases)
Doctor Examination
Physical Examination
After discussing your medical history and how the injury occurred, your doctor will do a careful examination of your ankle, lower leg, and foot.
Imaging Tests
If your doctor suspects an ankle fracture, they will order one or more of the following imaging tests to diagnose and evaluate the fracture
X-rays. Most ankle fractures can be diagnosed with X-rays. X-rays provide images of dense structures such as bone. They can show where the bones are broken and if any of the bones are out of place (displaced). They can also show how many pieces of broken bone there are. Your doctor may also take X-rays of the leg and foot to make sure there are no other injuries.
Depending on the type of ankle fracture, your doctor may put pressure on the ankle and take a special X-ray called a stress X-ray. This X-ray is done to determine if the syndesmosis (area between the lower tibia and fibula) is injured.
Computed tomography (CT) scan. A CT scan provides detailed cross-sectional X-ray images of the ankle and is sometimes done to further evaluate the ankle injury. It is helpful in evaluating the extent of the injury to the ankle joint.
Magnetic resonance imaging (MRI) scan. MRI scans provide high-resolution images of both bones and soft tissue structures, like ligaments. Because MRI scans are more sensitive than other imaging tests, they may be used to detect ligaments injuries.
Treatment
Treatment of ankle fractures depends on the type and severity of the injury.
Medial Malleolus Fracture
A medial malleolus fracture is a fracture of the lowest part of the tibia. Fractures of the medial malleolus may be isolated, but they are more commonly associated with fractures in other parts of the ankle.
Nonsurgical Treatment
A medial malleolus fracture that is not out of place (nondisplaced) can be treated with a short leg cast or walking boot. Your doctor may recommend that you avoid putting weight on your ankle for several weeks. During this time, the doctor will take X-rays to make sure that the fracture is healing properly.
Surgical Treatment
A medial malleolus fracture that is out of place (displaced) can be surgically repaired with one or two screws. If the fracture is large and extends into the ankle joint, a plate and screws may be required.
Lateral Malleolus Fracture
A lateral malleolus fracture is a fracture of the lower end of the fibula.
Nonsurgical Treatment
Similar to a nondisplaced medial malleolus fracture, a nondisplaced lateral malleolus fracture can often be treated with a short leg cast or walking boot. Most isolated lateral malleolus fractures are stable enough to allow you to put weight on the ankle.
Surgical Treatment
Surgical repair is necessary when a lateral malleolus fracture is displaced. The repair is typically done with a plate and screws. Usually, you will need to stay off the ankle for several weeks after surgery.
Posterior Malleolus Fracture
A posterior malleolus fracture is a fracture of the back of the tibia. Most posterior malleolus fractures are associated with another injury, usually a fracture of the lateral malleolus. This is due to attachments of ligaments between the two bones.
Nonsurgical Treatment
Many posterior malleolus fractures are small and do not require surgery. Treatment may involve wearing a short leg cast or a removable brace.
Surgical Treatment
Surgical fixation is required if the fracture is large and out of place. Typically, the surgical repair is done by placing screws in the lower tibia from front to back.
Bimalleolar Fracture and Bimalleolar Equivalent Fracture
A bimalleolar fracture occurs when both the medial malleolus and lateral malleolus are broken. Since there are injuries to both sides of the ankle, bimalleolar fractures are frequently unstable, and the ankle is often dislocated.
Nonsurgical Treatment
A stable bimalleolar fracture may be treated with cast immobilization for several weeks. During this time, you cannot put weight on your ankle. While you are in the cast, your doctor will take X-rays to make sure that the bones do not slip out of place.
Surgical Treatment
Because there are injuries to both sides of the ankle, most bimalleolar fractures need surgical repair. This is usually done with a plate and screws.
A bimalleolar equivalent fracture means that the ligaments on the inside (medial) part of the ankle are injured, and that only one bone has broken. The torn ligaments can cause the lower bone (talus) to shift and the ankle joint to go partially out of place or dislocate. Treatment involves putting the joint back in place and repairing the broken bone.
Trimalleolar Fracture
A trimalleolar fracture is similar to a bimalleolar injury except the posterior malleolus is also broken. Like bimalleolar fractures, these injuries are often unstable, and a dislocation can occur.
Most of the time, if the medial malleolus and lateral malleolus fractures are repaired, the posterior fragment will go back into place on its own. If the posterior fragment is out of place, surgical repair is required.
Syndesmosis Injury
The syndesmosis is a group of ligaments that stabilizes the small joint between the lower end of the fibula and the lower end of the tibia.
A syndesmosis injury that involves only the ligaments is often called a high ankle sprain. It can be usually treated without surgery but may take longer than a normal ankle sprain to heal.
A syndesmosis injury can also involve both a ligament sprain and one or more fractures. In these cases, surgery is required. In addition to repairing the fracture(s), the syndesmosis is repaired with one or more screws that can later be removed.
Recovery
The healing time for ankle fractures can vary depending on the extent of the injury. While most ankle fractures take at least 6 weeks to heal, it may take longer for any involved ligaments and tendons to heal.
Regardless of the type of treatment you receive, your doctor will most likely monitor the bone healing with repeated X-rays. This is typically done in the first 6 weeks.
Pain Management
After surgery, you will likely feel pain because this is a natural part of the healing process. Your doctor and nurses will work to reduce your pain. Typically, you will be given pain medicine intravenously (through an IV) in the first few hours after surgery. You will then be switched to oral pain medication. If you have not had surgery, you will be taking oral medication from the start.
Many types of oral medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and over-the-counter pain medication such as acetaminophen. Your doctor may use a combination of these medications to manage your pain, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor and to stop taking them as your pain begins to improve.
Rehabilitation
Rehabilitation is the key to your recovery, no matter which type of treatment you received.
Rehabilitation usually begins after your fractures have started to heal and your cast or walking boot has been removed. Your doctor will let you know when you can start putting weight on your ankle. They may also refer you to a physical therapist to start an exercise program.
It is very important to follow your doctor's instructions about weightbearing. If you put weight on the injured ankle too early, the fracture fragments may move out of place, and the fracture may not heal.
Your doctor may also recommend that you wear an ankle brace for sports for several months after your fracture has healed.
Complications After Ankle Fracture
Many patients will experience stiffness and swelling in the injured ankle for many months, even after the fracture has healed.
Rehabilitation will help improve the motion in your ankle and prevent stiffness. The swelling can be relieved by elevating your leg.
Other general complications include malunion, where the bones do not heal properly, or nonunion, where the bones do not heal at all.
Some complications are specific to surgery. These include:
- Infection
- Bleeding
- Damage to blood vessels, tendons, and nerves
- Problems with the plates or screws used to repair your ankle
- Arthritis
People who smoke, have diabetes, or are elderly are at a higher risk for complications after surgery.
Outcomes
Most people return to normal activities within 3 to 4 months after the injury occurs.
If your right ankle is affected, you can probably resume driving at 9 to 12 weeks. You may still be limping after several months, and it may take longer to return to sports.
Complete recovery from some ankle fractures may take up to 2 years.
Last Reviewed
September 2022
Contributed and/or Updated by
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AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.