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Ankle Fracture

  • Author: Kara Iskyan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
Updated: Dec 08, 2014


Ankle fractures refer to fractures of the distal tibia, distal fibula, talus, and calcaneus.

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint.

The true ankle joint contains the tibia (medial wall), fibula (lateral wall), and talus (the floor upon which the tibia and fibula rest). The true ankle joint allows dorsiflexion and plantar flexion or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward the ceiling via the true ankle joint.

The subtalar joint consists of the talus and the calcaneus. The subtalar joint allows the foot to be inverted or everted, that is, the sole of the foot can be made to face inward (inverted) or face outward (everted) through the subtalar joint.

During evaluation of ankle fractures, the mechanism of injury (eg, eversion, inversion, dorsiflexion, plantar flexion), associated injuries (eg, vascular, ligamentous, capsular), the need for immobilization (eg, application of a splint), and the need for referral to a specialist for further treatment or evaluation (eg, additional immobilization, surgery, or rehabilitation) are all important components of care.

For more information on fractures, see Medscape's Fracture Resource Center.



The primary motion of the ankle at the true ankle joint (tibiotalar joint) is plantarflexion and dorsiflexion.

Inversion and eversion occur at the subtalar joint.

Excessive inversion stress is the most common cause of ankle injuries for 2 anatomic reasons. First, the medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert. Second, the deltoid ligament stabilizing the medial aspect of the ankle joint offers stronger support than the thinner lateral ligaments. As a result, the ankle is more stable and resistant to eversion injury than inversion injury. However, when eversion injury occurs, there is often substantial damage to bony and ligamentous supporting structures and loss of joint stability.

Posterior malleolar fractures are usually associated with other fractures and/or ligamentous disruption. They are commonly associated with fibular fractures and are often unstable.

Transverse malleolar fractures usually represent an avulsion-type injury.

Vertical malleolar fractures result from talar impaction.




United States

Of all the ankle injuries evaluated in the ED, only 15% are ankle fractures. The frequency of ankle fractures has been increasing for the past 20 years, and the rate is approximately 187 in 100,000 person-years.


Patients with unrecognized or undertreated open ankle fractures are at high risk of infection including local infection, osteomyelitis, and sepsis. Gas gangrene is the most serious infectious complication. It can be both limb and life threatening.

Vascular supply to the ankle and foot may become compromised by development of a compartment syndrome[1] or direct injury to blood vessels from bone fragments.

Talus fractures, those commonly occurring in snowboarding trauma, can cause osteoarthritis and subtalar joint degeneration.

A calcaneal fracture may compromise inversion and eversion of the ankle. Surgical complications and prolonged rehabilitation are common with calcaneal fractures.

Older patients with ankle fractures experience more long-term complications than younger patients.


The male-to-female ratio for ankle fracture is 2:1. Most patients younger than 50 years are male, while most older than 50 years are female.


Pediatric ankle bones are susceptible to medial malleolar and transitional fractures of the distal tibia.

As the population ages, ankle fractures are becoming more common. An increase in fall risk and osteoporosis are risk factors.

Contributor Information and Disclosures

Kara Iskyan, MD Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General Hospital

Kara Iskyan, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.


Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, Association of Academic Chairs of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Jerome FX Naradzay, MD, to the development and writing of this article.

  1. Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. J Orthop Trauma. 1998 Jan. 12(1):67-8. [Medline].

  2. Shariff SS, Nathwani DK. Lauge-Hansen classification--a literature review. Injury. 2006 Sep. 37(9):888-90. [Medline].

  3. Michelson JD, Magid D, McHale K. Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma. 2007 May. 21(5):307-15. [Medline].

  4. Van Schie-Van der Weert EM, Van Lieshout EM, De Vries MR, Van der Elst M, Schepers T. Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures. Arch Orthop Trauma Surg. 2012 Feb. 132(2):257-63. [Medline]. [Full Text].

  5. Duchesneau S, Fallat LM. The Tillaux fracture. J Foot Ankle Surg. 1996 Mar-Apr. 35(2):127-33; discussion 189. [Medline].

  6. McCrory P, Bladin C. Fractures of the lateral process of the talus: a clinical review. "Snowboarder's ankle". Clin J Sport Med. 1996 Apr. 6(2):124-8. [Medline].

  7. Chan GM, Yoshida D. Fracture of the lateral process of the talus associated with snowboarding. Ann Emerg Med. 2003 Jun. 41(6):854-8. [Medline].

  8. Hinds RM, Garner MR, Lazaro LE, Warner SJ, Loftus ML, Birnbaum JF, et al. Ankle Fracture Spur Sign Is Pathognomonic for the Hyperplantarflexion Variant Ankle Fracture. Foot Ankle Int. 2014 Oct 2. [Medline].

  9. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). 2003 Apr. 15(2):126-32. [Medline].

  10. [Guideline] Dalinka MK, Alazraki NP, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, et al. Suspected ankle fractures. [online publication]. Reston (VA): American College of Radiology (ACR); 2005. [Full Text].

  11. Dowdall H, Gee M, Brison RJ, Pickett W. Utilization of radiographs for the diagnosis of ankle fractures in Kingston, Ontario, Canada. Acad Emerg Med. 2011 May. 18(5):555-8. [Medline].

  12. Dowling S, Spooner CH, Liang Y, Dryden DM, Friesen C, Klassen TP, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009 Apr. 16(4):277-87. [Medline].

  13. Petscavage J, Baker SR, Clarkin K, Luk L. Overuse of concomitant foot radiographic series in patients sustaining minor ankle injuries. Emerg Radiol. 2009 Oct 16. [Medline].

  14. Gonzalez O, Fleming JJ, Meyr AJ. Radiographic Assessment of Posterior Malleolar Ankle Fractures. J Foot Ankle Surg. 2014 Sep 25. [Medline].

  15. Alioto RJ, Furia JP, Marquardt JD. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. J Orthop Trauma. 1995 Apr. 9(2):113-6. [Medline].

  16. Barnett PL, Lee MH, Oh L, Cull G, Babl F. Functional outcome after air-stirrup ankle brace or fiberglass backslab for pediatric low-risk ankle fractures: a randomized observer-blinded controlled trial. Pediatr Emerg Care. 2012 Aug. 28(8):745-9. [Medline].

  17. Mora S, Zalavras CG, Wang L, et al. The role of pulsatile cold compression in edema resolution following ankle fractures: a randomized clinical trial. Foot Ankle Int. 2002 Nov. 23(11):999-1002. [Medline].

  18. Okcu G, Yercan HS. Is it possible to decrease skin temperature with ice packs under casts and bandages? A cross-sectional, randomized trial on normal and swollen ankles. Arch Orthop Trauma Surg. 2006 Dec. 126(10):668-73. [Medline].

  19. Birrer R, Cartwright T, Denton J. Immediate diagnosis of ankle trauma. The Physician and Sports Medicine. McGraw Hill; 1994. Vol 22: 95-103.

  20. Bucholz RW, Heckman JD. Fractures in adults. Rockwood and Green's Fractures in Adults. 5th ed. 2001.

  21. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem?. Acta Orthop Scand. 1998 Feb. 69(1):43-7. [Medline].

  22. Cummings RJ, Hahn GA. The incisural fracture. Foot Ankle Int. 2004 Mar. 25(3):132-5. [Medline].

  23. Daffner RH. Ankle trauma. Radiol Clin North Am. 1990 Mar. 28(2):395-421. [Medline].

  24. Derksen RJ, Bakker FC, Geervliet PC, et al. Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankleand foot rules by specialized emergency nurses. Am J Emerg Med. 2005 Oct. 23(6):725-9. [Medline].

  25. Duke Orthopaedics. Ankle Fractures. Wheeless' Textbook of Orthopaedics online. 2005. [Full Text].

  26. Fox A, Wykes P, Eccles K, et al. Five years of ankle fractures grouped by stability. Injury. 2005 Jul. 36(7):836-41. [Medline].

  27. Greenfield DM, Eastell R. Risk factors for ankle fracture. Osteoporos Int. 2001. 12(2):97-103. [Medline].

  28. Holroyd BR, Wilson D, Rowe BH, et al. Uptake of validated clinical practice guidelines: experience with implementing the Ottawa Ankle Rules. Am J Emerg Med. 2004 May. 22(3):149-55. [Medline].

  29. Kannus P, Palvanen M, Niemi S, et al. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone. 2002 Sep. 31(3):430-3. [Medline].

  30. Kirkpatrick DP, Hunter RE, Janes PC, et al. The snowboarder's foot and ankle. Am J Sports Med. 1998 Mar-Apr. 26(2):271-7. [Medline].

  31. Koury SI, Stone CK, Harrell G, et al. Recognition and management of Tillaux fractures in adolescents. Pediatr Emerg Care. 1999 Feb. 15(1):37-9. [Medline].

  32. Koval KJ, Lurie J, Zhou W, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005 Oct. 19(9):635-9. [Medline].

  33. Koval KJ, Zhou W, Sparks MJ, et al. Complications after ankle fracture in elderly patients. Foot Ankle Int. 2007 Dec. 28(12):1249-55. [Medline].

  34. Martin AG. Weber B ankle fracture: an unnecessary fracture clinic burden. Injury. 2004 Aug. 35(8):805-8. [Medline].

  35. Muthukumar T, Butt SH, Cassar-Pullicino VN. Stress fractures and related disorders in foot and ankle: plain films, scintigraphy, CT, and MR Imaging. Semin Musculoskelet Radiol. 2005 Sep. 9(3):210-26. [Medline].

  36. Nugent PJ. Ottawa Ankle Rules accurately asses injuries and reduce reliance on radiographs. J Fam Pract. 2004 Oct. 53(10):785-8. [Medline].

  37. Park JW, Kim SK, Hong JS, et al. Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma. 2002 Apr. 52(4):655-9. [Medline].

  38. Perry JJ, Stiell IG. Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury. 2006 Dec. 37(12):1157-65. [Medline].

  39. Ruiz E, Cicero J. Emergency Management of Skeletal Injuries. 1st ed. Mosby-Year Book, Incorporated; 1995. 517-541.

  40. Schmittenbecher PP. What must we respect in articular fractures in childhood?. Injury. 2005 Feb. 36 Suppl 1:A35-43. [Medline].

  41. Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa ankle rules. JAMA. 1994 Mar 16. 271(11):827-32. [Medline].

  42. Tang CW, Roidis N, Vaishnav S, et al. Position of the distal fibular fragment in pronation and supination ankle fractures: a CT evaluation. Foot Ankle Int. 2003 Jul. 24(7):561-6. [Medline].

  43. Thordarson DB. Detecting and treating common foot and ankle fractures: Part 1: The ankle and hindfoot. Phys Sportsmed. 1996 Sep. 24(9):

  44. Werner CM, Lorich DG, Gardner MJ, et al. Ankle fractures: it is not just a "simple" ankle fracture. Am J Orthop. 2007 Sep. 36(9):466-9. [Medline].

  45. Wexler RK. The injured ankle. Am Fam Physician. 1998 Feb 1. 57(3):474-80. [Medline].

Maisonneuve injury. Mortise view shows transverse fracture of the medial malleolus and widening of the tibiofibular syndesmosis without a fracture of the fibula. This injury is suggestive of a proximal fibula fracture (Maisonneuve fracture).
Pilon fracture in a 35-year-old man who fell 20 ft. Anteroposterior radiograph shows at least 2 fracture lines extending to the articular surface (plafond) of the tibia.
A 13-year-old girl with triplane fracture. Anteroposterior radiograph shows a sagittal component through the distal tibia epiphysis.
An 11-year-old girl with juvenile Tillaux fracture. Mortise view shows fracture involving the lateral portion of tibial epiphysis.
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