Ankle Fracture in Sports Medicine Treatment & Management
- Author: John D Kelly, IV, MD; Chief Editor: Sherwin SW Ho, MD more...
As always, acute management of ankle fractures involves analgesics for pain, immobilization, and patient comfort. Use either a well-padded posterior splint or a stirrup splint to keep the patient from bearing weight on the ankle until definitive treatment is instituted in 3-4 days.
Small avulsion Danis-Weber type A fractures without medial-sided injury can be symptomatically treated with a walking cast or stirrup brace and ambulation as tolerated. The patient should apply ice to the injured area over a compressive dressing for 20 minutes every 2-3 hours for the first 24 hours and every 4-6 hours thereafter until casting. Keeping the limb elevated above the level of the heart also significantly reduces swelling.
Isolated lateral malleolus fractures are the most common fracture involving the ankle. Most inversion injuries result in an isolated sprain of the anterior talofibular ligament. However, a small avulsion fracture can occasionally be seen near the distal portion of the lateral malleolus. Barely visible osseous chip fractures do not alter the routine active management of grade 1 and 2 ankle sprains.
Most primary care physicians can treat isolated nondisplaced Danis-Weber type A fractures. 
More experienced providers can treat stable, nondisplaced fractures of the malleoli with posterior malleolus involvement of less than 25% of the articular surface.
Bimalleolar or trimalleolar injuries are always unstable and are treated with open reduction and internal fixation. All displaced medial malleolar fractures are openly reduced and fixed to restore normal ankle congruency and deltoid integrity.
Referral to an orthopedist is advisable for all displaced ankle fractures, because minor changes involving the joint mortise can cause chronic pain and early osteoarthritis. Patients with possible unstable injury (Danis-Weber classification types B or C) or those with bimalleolar fractures should be referred to an orthopedist. In the presence of medial malleolar tenderness and more than 5 mm of medial clear space on the mortise view, make a presumptive diagnosis of deltoid ligament rupture if a displaced fibular fracture is present. Treat these injuries as a bimalleolar fracture, and refer patients with this injury for treatment by an orthopedist.
Referral is also indicated for all trimalleolar fractures, which involve fracture to both the medial and lateral malleoli, along with a fracture to the posterior lip of the tibial plafond. This fracture is usually secondary to an avulsion of the posterior tibiofibular ligament at its insertion site. Fractures that show no radiographic evidence of healing after 8 weeks are best evaluated for adjunctive measures.
After the acute phase, cast immobilization can be accomplished with either a short leg walking cast or walking cast fracture boot in a reliable patient with a stable ankle fracture.
The ankle should be put in a cast in a neutral position to avoid shortening of the Achilles tendon. Generally, 4-6 weeks of immobilization is required for healing. Cast boots are generally preferred after swelling dissipates so that intermittent motion can commence. If the fracture site is not tender, gradual ankle rehabilitation can begin because clinical healing is present. If no evidence of fracture healing is present, an additional 2-4 weeks of immobilization may be required.
If no evidence of fracture healing is present by 8 weeks, referral to an orthopedist is mandatory.
After completing the immobilization period, the patient should begin ankle rehabilitation. Range of motion and strength returns quickly in young patients, and referral to a physical therapist may not be necessary. Patients motivated to complete rehabilitation at home can perform calf stretching and strengthening exercises, along with range-of-motion activities. Instruct patients to pay particular attention to the attainment of dorsiflexion. Older patients with premorbid conditions often require formal physical therapy to successfully regain strength and range of motion in the ankle.
Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP. Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop (Belle Mead NJ). 2011 Jan. 40(1):40-4. [Medline].
Czajka CM, Tran E, Cai AN, DiPreta JA. Ankle sprains and instability. Med Clin North Am. 2014 Mar. 98 (2):313-29. [Medline].
Newman JS, Newberg AH. Basketball injuries. Radiol Clin North Am. 2010 Nov. 48(6):1095-111. [Medline].
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].
Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports Med. 1997 Jul. 16(3):435-66. [Medline].
Miller TL, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med. 2014 Feb. 44 (2):179-88. [Medline].
Tayeb R. Diagnostic value of Ottawa ankle rules: simple guidelines with high sensitivity. Br J Sports Med. 2013 Jul. 47(10):e3. [Medline].
Tandeter HB, Shvartzman P. Acute ankle injuries: clinical decision rules for radiographs. Am Fam Physician. 1997 Jun. 55(8):2721-8. [Medline].
Schwartz DT, Reisdorff E, Williamson B, eds. Emergency Radiology. New York, NY: McGraw-Hill; 1999.
Wedmore IS, Charette J. Emergency department evaluation and treatment of ankle and foot injuries. Emerg Med Clin North Am. 2000 Feb. 18(1):85-113, vi. [Medline].
Yu JS, Cody ME. A template approach for detecting fractures in adults sustaining low-energy ankle trauma. Emerg Radiol. 2009 Feb 18. epub ahead of print. [Medline].
Robertson GA, Wood AM, Aitken SA, Court Brown C. Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population. Foot Ankle Int. 2014 Nov. 35 (11):1143-52. [Medline].
Del Buono A, Smith R, Coco M, Woolley L, Denaro V, Maffulli N. Return to sports after ankle fractures: a systematic review. Br Med Bull. 2013. 106:179-91. [Medline].
Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. 2009 Feb. 91(2):333-9. [Medline].
Zalavras CG, Christensen T, Rigopoulos N, Holtom P, Patzakis MJ. Infection following operative treatment of ankle fractures. Clin Orthop Relat Res. 2009 Feb 19. epub ahead of print. [Medline].