Overview of ankle fractures in adults
- Scott M Koehler, MD
Scott M Koehler, MD
- Physician, Sports Medicine Specialist
- Allina Health, Northfield, Minnesota
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Section Editor
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Ankle fractures are increasingly common injuries that necessitate a careful approach for proper management. Over five million ankle injuries occur each year in the United States alone .
This topic review will provide an overview of ankle fractures that result from minor trauma (ie, indirect or low energy fractures), including a basic approach to their evaluation and management. Fibular fractures above the lateral malleolus, tibial fractures, and ankle injuries other than fractures are discussed elsewhere. (See "Fibula fractures" and "Overview of tibial fractures in adults" and "Ankle sprain" and "Non-Achilles ankle tendinopathy".)
EPIDEMIOLOGY AND RISK FACTORS
The incidence of ankle fractures is approximately 187 fractures per 100,000 people each year . Since the mid-1900s, this rate has increased significantly in many industrialized countries, most likely due to growth in the number of people involved in athletics and in the size of the elderly population [1-3].
The vast majority of ankle fractures are malleolar fractures: 60 to 70 percent occur as unimalleolar fractures, 15 to 20 percent as bimalleolar fractures, and 7 to 12 percent as trimalleolar fractures [1,4]. There are similar fracture rates overall between women and men, but men have a higher rate as young adults, while women have higher rates in the 50 to 70-year age group [1,4].
Cigarette smoking and a high body mass index have been associated with ankle fractures [5,6]. In contrast to fractures of the radius and other fractures common among perimenopausal and postmenopausal women, bone density has not been clearly demonstrated to be a major risk factor .
- Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 1987; 58:539.
- Jensen SL, Andresen BK, Mencke S, Nielsen PT. Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand 1998; 69:48.
- Marsh, JL, Saltzman, CL. Ankle Fractures. In: Rockwood and Green's Fractures in Adults, Bucholz, RW and Heckman, JD (Eds), Lippincott Williams and Wilkins, Philadelphia 2002. p.2001.
- Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures--an increasing problem? Acta Orthop Scand 1998; 69:43.
- Valtola A, Honkanen R, Kröger H, et al. Lifestyle and other factors predict ankle fractures in perimenopausal women: a population-based prospective cohort study. Bone 2002; 30:238.
- Honkanen R, Tuppurainen M, Kröger H, et al. Relationships between risk factors and fractures differ by type of fracture: a population-based study of 12,192 perimenopausal women. Osteoporos Int 1998; 8:25.
- Seeley DG, Kelsey J, Jergas M, Nevitt MC. Predictors of ankle and foot fractures in older women. The Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1996; 11:1347.
- Simon, RR, Koenigsknecht, SJ. Fractures of the Ankle. In: Emergency Orthopedics: The Extremities, McGraw-Hill, New York 2001. p.497.
- Michelson JD. Fractures about the ankle. J Bone Joint Surg Am 1995; 77:142.
- Gardner MJ, Demetrakopoulos D, Briggs SM, et al. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma 2006; 20:267.
- Michelson J, Solocoff D, Waldman B, et al. Ankle fractures. The Lauge-Hansen classification revisited. Clin Orthop Relat Res 1997; :198.
- Carr, JB. Malleolar fractures and soft tissue injuries of the ankle. In: Skeletal trauma: Basic science, management and reconstruction, 3rd edition, Browner, BD, Jupiter, JB, Levine, AM, Trafton, PG (Eds), Saunders, Philadelphia 2003. p.2326.
- Odak S, Ahluwalia R, Unnikrishnan P, et al. Management of Posterior Malleolar Fractures: A Systematic Review. J Foot Ankle Surg 2016; 55:140.
- Markert RJ, Walley ME, Guttman TG, Mehta R. A pooled analysis of the Ottawa ankle rules used on adults in the ED. Am J Emerg Med 1998; 16:564.
- van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg 2009; 129:227.
- Nortunen S, Flinkkilä T, Lantto I, et al. Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures. Bone Joint J 2015; 97-B:1126.
- Irwin TA, Lien J, Kadakia AR. Posterior malleolus fracture. J Am Acad Orthop Surg 2013; 21:32.
- Willett K, Keene DJ, Mistry D, et al. Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults: A Randomized Clinical Trial. JAMA 2016; 316:1455.
- Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database Syst Rev 2012; :CD008470.
- Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures. Acta Orthop Scand 1985; 56:103.
- Kristensen KD, Hansen T. Closed treatment of ankle fractures. Stage II supination-eversion fractures followed for 20 years. Acta Orthop Scand 1985; 56:107.
- Pakarinen HJ, Flinkkil TE, Ohtonen PP, Ristiniemi JY. Stability criteria for nonoperative ankle fracture management. Foot Ankle Int 2011; 32:141.
- Moseley AM, Beckenkamp PR, Haas M, et al. Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial. JAMA 2015; 314:1376.
- Lin CW, Donkers NA, Refshauge KM, et al. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev 2012; 11:CD005595.
- Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. J Bone Joint Surg Am 2008; 90:1570.
- SooHoo NF, Krenek L, Eagan MJ, et al. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg Am 2009; 91:1042.
- Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int 2008; 29:1184.
- Davidovitch RI, Walsh M, Spitzer A, Egol KA. Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int 2009; 30:728.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- Malleolar fractures
- CLINICAL PRESENTATION AND EXAMINATION
- RADIOGRAPHIC FINDINGS
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- Initial treatment
- Management of specific malleolar fractures
- - Lateral malleolar fractures
- - Isolated medial or posterior malleolar fractures
- - Lateral malleolar fractures with deltoid ligament injury
- - Bimalleolar and trimalleolar fractures
- REHABILITATION AFTER ANKLE FRACTURE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS