eMedicine Specialties > Sports Medicine > Foot and Ankle

Ankle Fracture: Differential Diagnoses & Workup

Author: Phillip M Steele, MD, Consulting Staff, Primary Care Sports Medicine, Gem City Bone and Joint; Team Physician, University of Wyoming
Coauthor(s): John D Kelly IV, MD, Associate Professor of Orthopedic Surgery, Vice Chairman, Department of Orthopedic Surgery, Temple University; Consulting Surgeon, Temple Children's Hospital and Shriner's Hospital for Surgery
Contributor Information and Disclosures

Updated: Mar 9, 2009

Differential Diagnoses

Talofibular Ligament Injury

Other Problems to Be Considered

Cuboid fracture or dislocation
Fifth metatarsal fracture
Fracture of anterior process of calcaneus
Fracture of lateral process of talus
Osteochondritis dissecans of talus
Peroneal tendon dislocation

Workup

Laboratory Studies

  • No routine laboratory studies are indicated in patients with an ankle fracture unless syncope or other medical conditions are involved.

Imaging Studies

  • Radiographs in patients with a suspected ankle fracture should include anteroposterior, lateral, and mortise views (which are taken with the foot internally rotated 15-20°).4,5,6,7 The mortise view eliminates the overlapping shadow of the tibia on the fibula. Stress-view radiographs have a limited role in evaluating an acute ankle injury. They should only be taken while a patient is under anesthesia before reconstructive surgery. A standing mortise view of the ankle can help identify ligamentous instability in patients who are difficult to examine. Comparison of the normal radiographic relationships from the mortise and standing mortise views shows loss of the normal tibiofibular overlap and asymmetry of clear spaces. A comparison view with the uninjured ankle can be useful in difficult cases.
    • When reviewing ankle radiographs, consider that transverse fractures usually result from avulsion forces, whereas oblique fractures (usually fibular) generally result from torsional stress of the talus against the malleolus. Vertical malleolar fractures are secondary to an impact on the talus. Any displaced malleolar fracture should be considered unstable, and they are almost always associated with ligamentous injury of the opposite side. In general, all displaced medial malleolus fractures and oblique fibular fractures that are 2-3 inches proximal to the joint line should be assumed to have associated ligament injury and should be considered unstable.
    • In addition to using the radiographic guidelines of alignment, bone, and connective tissue to evaluate ankle radiographs, checking for the 5 most commonly missed foot and ankle fractures is advised. Close attention to the fifth metatarsal base, lateral process of the talus, os trigonum or posterior malleolus, anterior process of the calcaneus, and talar dome (forming the mnemonic FLOAT) can help clinicians correlate radiographic findings with tenderness upon physical examination.
  • The radiographic relationships of the ankle mortise view are as follows:
    • A lateral clear space of more than 2 mm suggests a syndesmosis sprain.
    • The normal tibiofibular overlap is greater than 1 mm.
    • The normal medial clear space is less than 4 mm or a difference from medial to lateral of less than 2 mm.
  • Radiographic relationships of the anteroposterior ankle view are as follows:
    • A medial clear space of more than 3 mm may indicate deltoid ligament or syndesmosis injury.
    • The tibiofibular space is normally less than 6 mm.
    • In the standing anteroposterior view, syndesmotic widening of greater than 3 mm indicates syndesmotic sprain.

More on Ankle Fracture

Overview: Ankle Fracture
Differential Diagnoses & Workup: Ankle Fracture
Treatment & Medication: Ankle Fracture
Follow-up: Ankle Fracture
Multimedia: Ankle Fracture
References
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References

  1. Michelson JD. Fractures about the ankle. J Bone Joint Surg Am. Jan 1995;77(1):142-52. [Medline]. [Full Text].

  2. Thordarson DB. Detecting and treating common foot and ankle fractures. Part 1: the ankle and hindfoot. Phys Sportsmed. Sept 1996;24(9):29-38. [Full Text].

  3. Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports Med. Jul 1997;16(3):435-66. [Medline].

  4. Tandeter HB, Shvartzman P. Acute ankle injuries: clinical decision rules for radiographs. Am Fam Physician. Jun 1997;55(8):2721-8. [Medline].

  5. Schwartz DT, Reisdorff E, Williamson B, eds. Emergency Radiology. New York, NY: McGraw-Hill; 1999.

  6. Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. Feb 2000;18(1):85-113, vi. [Medline].

  7. Yu JS, Cody ME. A template approach for detecting fractures in adults sustaining low-energy ankle trauma. Emerg Radiol. Feb 18 2009;epub ahead of print. [Medline].

  8. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. Feb 2009;91(2):333-9. [Medline].

  9. Zalavras CG, Christensen T, Rigopoulos N, Holtom P, Patzakis MJ. Infection following operative treatment of ankle fractures. Clin Orthop Relat Res. Feb 19 2009;epub ahead of print. [Medline].

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Further Reading

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Keywords

ankle fracture distal, distal ankle fracture, tibia distal fibular injury, medial malleolus, lateral malleolus, malleoli, tibial plafond, Ottawa ankle rules, OAR, broken ankle, sprained ankle, ankle sprain, ankle injury, distal fibular fracture, distal tibial fracture, malleolus fracture, lateral malleolus fracture, Danis-Weber classification, Danis-Weber fracture, Jones fracture, Salter-Harris classification, Salter-Harris fracture

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Contributor Information and Disclosures

Author

Phillip M Steele, MD, Consulting Staff, Primary Care Sports Medicine, Gem City Bone and Joint; Team Physician, University of Wyoming
Phillip M Steele, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John D Kelly IV, MD, Associate Professor of Orthopedic Surgery, Vice Chairman, Department of Orthopedic Surgery, Temple University; Consulting Surgeon, Temple Children's Hospital and Shriner's Hospital for Surgery
John D Kelly IV, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Pennsylvania Orthopaedic Society, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Adolescent and Sports Medicine Fellowship, Associate Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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