eMedicine Specialties > Radiology > Musculoskeletal

Ankle, Fractures

Author: Michael E Mulligan, MD, Associate Professor, Assistant Chief of Musculoskeletal Imaging, Department of Radiology, University of Maryland School of Medicine; Chief, Division of Radiology, Kernan Hospital
Contributor Information and Disclosures

Updated: Feb 20, 2009

Introduction

Background

The ankle is one of the most frequently injured areas of the skeleton. Although many of these injuries are ligament sprains, the radiologist plays a key role in the thorough evaluation of complex injuries and the detection of subtle fractures.1,2,3,4

Diagram showing the typical locations for ankle f...

Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection.

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Diagram showing the typical locations for ankle f...

Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection.


For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Ankle Fracture.

Related eMedicine topics:

Fracture, Ankle (from Emergency Medicine)

Ankle Fracture (from Sports Medicine)

Joint Reduction, Ankle Dislocation

Ankle Arthroscopy

Splinting, Ankle

Anatomy

The shapes of the ankle bones and the supporting ligamentous structures are important anatomic features of the ankle area. The distal tibia has a large, flat articular surface (the plafond), a prominent medial malleolus, and a less prominent posterior malleolus. The talar dome is wedge-shaped, wider anteriorly than posteriorly.

The distal fibula or lateral malleolus is bound to the distal tibia by the anterior and posterior inferior tibiofibular ligaments, an inferior transverse ligament, and a syndesmosis ligament. The fibula is also bound to the talus by the anterior and posterior talofibular ligaments and to the calcaneus by the calcaneofibular ligament. The medial malleolus is bound to the talus, calcaneus, and navicular by the superficial and deep portions of the deltoid ligament.

Presentation

Patients with an ankle fracture usually will not be able to bear weight on the ankle and will have more swelling and pain than patients with just a ligament sprain. A site of point tenderness is often present with an ankle fracture, and an obvious deformity may be seen. The Ottawa Ankle Rules, developed by Stiell et al in Ottawa, Canada, are a set of guidelines that are used to determine whether radiography is necessary.5,6

Preferred Examination

Brandser et al emphasized the necessity of obtaining 3 conventional radiographs in anteroposterior, internal oblique (mortise), and lateral projections.7 Other imaging studies, such as arthrography, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine, are rarely used. Radiographic stress views may be done, although they can be difficult to obtain. Stress views with dorsiflexion and external rotation of the ankle were reported by Park et al to best show tears of the deltoid ligament by resultant widening of the medial clear space when measured at 5 mm or more.8

Limitations of Techniques

Despite the use of the standard 3-view conventional radiographic survey, some ankle fractures cannot be seen at the time of initial evaluation. The presence of a large ankle-joint effusion on the initial lateral radiograph suggests an occult fracture. One third of patients with an effusion measuring 13 mm or more had occult fractures in a series reported by Clark et al.9 The radiographic appearance often suggests the presence of associated ligamentous injuries, but Gardner et al showed, in a series of 59 patients, that MRI is much more specific for ligamentous injuries.10  Additionally, although radiographic widening of the syndesmotic space of greater than 5 mm is reported to be abnormal, Nielson et al, in an MRI series of 70 patients, found no association between the MRI findings of syndesmotic injury and the radiographic measurements.11  

Differential Diagnoses

Ankle Arthroscopy
Metatarsalgia
Ankle Fracture
Metatarsals, Fractures
Ankle Impingement Syndrome
Ankle Sprain
Metatarsal Stress Fracture

Other Problems to Be Considered

Ankle sprain
Fifth metatarsal fracture
Talar dome osteochondral injury
Other surrounding ligament or tendon injury

More on Ankle, Fractures

Overview: Ankle, Fractures
Imaging: Ankle, Fractures
Follow-up: Ankle, Fractures
Multimedia: Ankle, Fractures
References
Further Reading
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References

  1. Ng A, Barnes ES. Management of complications of open reduction and internal fixation of ankle fractures. Clin Podiatr Med Surg. Jan 2009;26(1):105-25. [Medline].

  2. Early JS. Talus fracture management. Foot Ankle Clin. Dec 2008;13(4):635-57. [Medline].

  3. Clare MP. A rational approach to ankle fractures. Foot Ankle Clin. Dec 2008;13(4):593-610. [Medline].

  4. Lo EY, Lee MA. New concepts in the surgical management of ankle fractures. Orthopedics. Sep 2008;31(9):868-72. [Medline].

  5. Stiell IG, Greenberg GH, McKnight RD, et al. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. Apr 1992;21(4):384-90. [Medline].

  6. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. Mar 3 1993;269(9):1127-32. [Medline].

  7. Brandser EA, Berbaum KS, Dorfman DD, et al. Contribution of individual projections alone and in combination for radiographic detection of ankle fractures. AJR Am J Roentgenol. Jun 2000;174(6):1691-7. [Medline].

  8. Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma. Jan 2006;20(1):11-8. [Medline].

  9. Clark TW, Janzen DL, Ho K, et al. Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion. AJR Am J Roentgenol. May 1995;164(5):1185-9. [Medline].

  10. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma. Apr 2006;20(4):267-72. [Medline].

  11. Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. Jul 2005;(436):216-21. [Medline].

  12. Mulligan ME. Ankle fracture classifications clarified. Radiol. 1998;5:127-136.

  13. Sorrento DL, Mlodzienski A. Incidence of lateral talar dome lesions in SER IV ankle fractures. J Foot Ankle Surg. Nov-Dec 2000;39(6):354-8. [Medline].

  14. Sclafani SJ. Ligamentous injury of the lower tibiofibular syndesmosis: radiographic evidence. Radiology. Jul 1985;156(1):21-7. [Medline].

  15. Pankovich AM. Trauma to the ankle. In: Jahos MH. Disorders of the Foot and Ankle. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1991:2361-2414.

  16. Yde J. The Lauge Hansen classification of malleolar fractures. Acta Orthop Scand. Feb 1980;51(1):181-92. [Medline].

  17. Cheung Y, Perrich KD, Gui J, Koval KJ, Goodwin DW. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted?. AJR Am J Roentgenol. Jan 2009;192(1):W7-12. [Medline].

  18. Hsu CC, Tsai WC, Chen CP, Chen MJ, Tang SF, Shih L. Ultrasonographic examination for inversion ankle sprains associated with osseous injuries. Am J Phys Med Rehabil. Oct 2006;85(10):785-92. [Medline].

  19. Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed). Feb 21 1981;282(6264):606-7. [Medline].

  20. Cockshott WP, Jenkin JK, Pui M. Limiting the use of routine radiography for acute ankle injuries. Can Med Assoc J. Jul 15 1983;129(2):129-31. [Medline].

  21. Vangsness CT Jr, Carter V, Hunt T, et al. Radiographic diagnosis of ankle fractures: are three views necessary?. Foot Ankle Int. Apr 1994;15(4):172-4. [Medline].

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Keywords

ankle fracture, broken ankle, fractured ankle, broken ankle bone, fractured ankle bone, fractured anklebone, broken anklebone, Ottawa ankle rules, broken foot, fractured foot, sprained ankle, twisted ankle

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Contributor Information and Disclosures

Author

Michael E Mulligan, MD, Associate Professor, Assistant Chief of Musculoskeletal Imaging, Department of Radiology, University of Maryland School of Medicine; Chief, Division of Radiology, Kernan Hospital
Michael E Mulligan, MD is a member of the following medical societies: American Roentgen Ray Society, International Skeletal Society, Radiological Society of North America, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Medical Editor

Amilcare Gentili, MD, Clinical Professor of Radiology, University of California at San Diego; Consulting Staff, Department of Radiology, Thornton Hospital
Amilcare Gentili, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Theodore E Keats, MD, Professor, Departments of Radiology and Orthopedics, University of Virginia School of Medicine
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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