Ankle Fracture in Sports Medicine Clinical Presentation

The following important questions should be included in the history of the patient suspected of an ankle fracture:

• What was the mechanism of the injury? Was it inversion or eversion; external or internal rotation? Many patients cannot recall whether their foot was plantarflexed or dorsiflexed; if the patient does know the position, this information is useful in assessing stability.

• Was the patient able to bear weight after the injury? The Ottawa ankle rules specify that the inability to bear weight immediately after the injury or at the time of the radiograph is taken indicates the need for radiographic examination because of the increased risk of a clinically significant fracture. ^{[9, 2]}

• Is there or was there an audible sound (eg, a pop)?

• Is there a history of previous trauma to the ankle?

Begin the physical examination of the ankle by inspecting for swelling and ecchymosis and by palpating for areas of maximal tenderness. However, swelling is time-dependent and may be an unreliable indicator of the presence or the severity of the ankle injury. Generally, more severe injuries are accompanied by more severe swelling.

• Using light touch, palpate the medial and lateral malleolus for crepitation.

• Assess the range of motion in plantar flexion, dorsiflexion, inversion, and eversion.

• Assess ligamentous laxity with talar tilt and drawer testing.

• Assess and document the neurovascular status.

• Begin palpation of the medial and lateral malleoli at the distal posterior margins, because the incidence of a false-positive result is increased when palpating the anterior portions.

  • The Ottawa ankle rules specify that if a patient demonstrates tenderness at the posterior malleoli (up to and including the crest), then the likelihood of an ankle fracture is increased and radiography should be performed. ^{[9, 10, 11, 12, 13]}

  • Failure to palpate the entire distal 6 cm of both malleoli is a common error made by physicians and primary care providers. Failure to do so increases the likelihood of missing a clinically significant ankle fracture.

  • Palpate over the tibial and fibular physis in children. If tender, assume the patient has a type I Salter-Harris classification of epiphysial plate injury, even if radiographic findings are negative.

  • Crepitation felt during palpation of the ankle is suggestive of underlying fracture pathology and necessitates radiologic examination.

• Check the joint above and below the area of the patient's chief complaint in order to not miss concomitant adjacent fractures.

• Palpate over the proximal fifth metatarsal and navicular for tenderness.

• Palpate the soft tissues, including ligamentous areas, peroneal and posterior tibial tendons, and the anterior process of the calcaneus, to assess injury to these areas.

• Palpate for tenderness over the proximal fibula to exclude potential Maisonneuve fracture (proximal fibular fracture associated with medial-sided and syndesmotic injury).

• Assess strength in resisted external and internal rotation, ankle plantarflexion, dorsiflexion, supination, and pronation.

Fracture classification

Ankle fractures can be classified as single malleolar, bimalleolar, and trimalleolar if the posterior part of the tibial plafond is involved. Careful attention must be paid to all single malleolar fractures because ligament instability is frequently associated with the contralateral side. Distal fibula fractures are the most common fracture type to the ankle, and the Danis-Weber classification system is listed below.

• The Danis-Weber classification for ankle fractures is simple and is the most useful for primary care management. This classification scheme is based on the level of the fracture in relationship to the joint mortise of the distal fibula.

  • Type A fractures are horizontal avulsion fractures found below the mortise. They are stable and amenable to treatment with closed reduction and casting unless accompanied by a displaced medial malleolus fracture.

  • Type B fracture is a spiral fibular fracture that starts at the level of the mortise. This type of fracture occurs secondary to external rotational forces. These fractures may be stable or unstable depending on ligamentous injury or associated fractures on the medial side.

  • Type C fracture is above the level of the mortise and disrupts the ligamentous attachment between the fibula and the tibia distal to the fracture. These fractures are unstable and require open reduction and internal fixation.