Treatment of Foot and Ankle Fractures
Ankle Fracture
The ankle joint is comprised of three bones: the tibia, fibula, and talus which articulate together. The ends of the fibula and tibia (lower leg bones) form the inner and outer malleolus, which are the bony protrusions of the ankle joint that you can feel and see on either side of the ankle. The joint is protected by a fibrous membrane called a joint capsule, which is filled with synovial fluid to enable smooth movement.
Ankle injuries are common in athletes and patients engaged in physical work, often resulting in severe pain and impaired mobility. Pain associated with ankle injuries may be the result of a torn ligament (“sprain”) or a broken bone (“fracture”). An ankle fracture is a painful condition involving a break in one or more bones forming the ankle joint. The ankle joint is stabilized by different ligaments and other soft tissues, which may also be injured when an ankle fracture is suffered. In severe cases, the fracture may result in one of the ankle bones piercing and protruding through the skin. This is called an open fracture and typically requires multiple surgeries.
Causes
Ankle fractures usually result from trauma or excessive rolling and twisting of the ankle, which are generally caused by a specific accident or a variety of physical activities such as jumping or falling that places stress on the joint.
Symptoms
Ankle fractures, generally result in immediate swelling and pain around the ankle as well as impaired mobility. In some cases, blood may accumulate around the damaged joint, a condition called hemarthrosis. Additionally, bruising and redness occur at the ankle and foot and sometimes fracture blisters appear in severe cases.
Types of Fractures
Ankle fractures are classified according to the location and type of ankle bone involved. The different types of ankle fractures are generally classified as follows:
- Lateral Malleolus fracture - the lateral malleolus, or outer part of the ankle, is fractured.
- Medial Malleolus fracture - the medial malleolus, or inner part of the ankle, is fractured.
- Posterior Malleolus fracture - the posterior malleolus, or bony hump of the tibia, is fractured.
- Bimalleolar fracture - both lateral and medial malleolus bones are fractured.
- Trimalleolar fractures – the lateral, medial, and posterior malleolus bones are all fractured.
- Syndesmotic injury - also called a high ankle sprain, is generally not considered a fracture but may be treated as a fracture since it causes ankle instability and long-term complications.
Diagnosis
Diagnosis of an ankle injury begins with a physical examination and is usually followed by an X-ray and possibly a CT scan for a more detailed view. Without a radiologic study such as an x-ray or CT scan, it may be difficult to differentiate a broken ankle bone from other conditions such as a sprain, dislocation, or tendon injury. Depending on the nature of the injury, the physical examination may include a “stress test” which evaluates the stability of a suspected ankle fracture, which, in turn, may determine whether surgery is necessary. In complex cases, a detailed evaluation of supporting ligaments through an MRI scan may be recommended.
Treatments
Immediately following an ankle injury (and prior to seeing a provider), patients should apply ice packs and keep their injured ankle elevated, to minimize pain and swelling.
Treatment of an ankle fracture usually depends on both the type and stability of the fractured bone. Treatment usually begins with non-surgical methods, in order to decrease soft tissue swelling. However, in cases where the fracture is unstable and/or cannot be realigned, surgical treatment may be required right away.
With non-surgical treatment, the ankle bone is realigned, and a plaster splint is placed around the joint, for at least 2-3 weeks.
With surgical treatment, the fractured bone is usually accessed by making an incision over the ankle and then the broken pieces are aligned and compressed together. The bones are fixated with screws and usually, a metal plate is then placed on top for
added protection and support. The incision is then sutured closed, and the ankle is immobilized with a splint.
Post-Operative Care
After ankle surgery, patients are instructed to avoid placing weight on the ankle by using crutches, a walker, and/or a knee scooter for at least six weeks.
Physical therapy is usually necessary to rehabilitate the ankle after surgery. After 2-3 months of physical therapy, the patient may be able to perform normal daily activities. High-impact activities can usually be resumed 6 months post-operatively.
Risks and Complications
Some of the risks and complications associated with ankle fractures include decreased ankle range of motion/stiffness, chronic pain, ankle arthritis, wound complications, infection, and/or nerve damage resulting in pain.
Although not usual, surgery may result in incomplete healing of the fracture, which could require subsequent revision surgery to repair. This risk/complication is more common in patients who use nicotine products and those with uncontrolled diabetes.
Foot Fracture
The foot usually consists of 26 bones, and includes 3 distinct parts:
The hind foot is comprised of two bones, the talus bone which connects to the bones of the lower leg, and the calcaneus bone which forms the heel.
The midfoot is comprised of the navicular, cuboid, and three cuneiform bones.
The forefoot is comprised of five metatarsal bones and 14 toe bones called phalanges.
The hind foot is separated from the midfoot by the transverse tarsal joint, also known as the Chopart joint. This includes the talonavicular joint as well as the calcaneocuboid joints. The midfoot is separated from the forefoot by the Lisfranc joint. The Lisfranc joint separates the five metatarsal bones from the three cuneiform bones and the cuboid bone.
Muscles, tendons, and ligaments support the bones and joints of the feet enabling them to withstand the entire body’s weight while walking, running, and jumping. Trauma and/or stress can cause fractures in the foot. Extreme force is required to fracture the bones in the hindfoot. The most common type of foot fracture is a stress fracture, which occurs when repeated activities produce small cracks in the bone. Patients with low bone density (osteopenia or osteoporosis) are at higher risk for stress fractures.
Figure 2: Blue line separates the forefoot from the midfoot.
Red line separates the midfoot from the hindfoot.
Types of foot fractures
Foot fractures can involve different bones and joints, and are generally classified into the following types:
Calcaneal fractures:
This type affects the heel bone and usually occurs as a result of a high-energy
collision or a fall from height. It can cause disabling injuries, and if the subtalar joint is involved it is considered a severe fracture.
Talar fracture:
The talus bone helps to transfer weight and forces across the joint. Talus fractures usually occur at the neck or mid portion of the talus.
Navicular fracture:
Navicular fractures although rare, usually consist of stress fractures that occur with sports activities involving repeated loading on the foot, such as running and gymnastics.
Lisfranc fracture:
This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments. These fractures typically cause instability in the midfoot and lead to midfoot arthritis if left untreated.
This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments. These fractures typically cause instability in the midfoot and lead to midfoot arthritis if left untreated.
Metatarsal fracture:
Metatarsal fractures of the 2nd through 5th metatarsals can usually be treated nonoperatively unless there is significant displacement. Typically, patients are able to weight bear as tolerated in a walking boot or post-operative shoe. They can then transition to supportive sneakers as symptoms continue to improve. Patients are usually back into a regular shoe within 4-6 weeks after injury.
Metatarsal fractures of the 2nd through 5th metatarsals can usually be treated nonoperatively unless there is significant displacement. Typically, patients are able to weight bear as tolerated in a walking boot or post-operative shoe. They can then transition to supportive sneakers as symptoms continue to improve. Patients are usually back into a regular shoe within 4-6 weeks after injury.
Toe fracture:
Toe fractures usually occur after trauma such as dropping a heavy object on the foot or kicking a stationary object. These can typically be treated non-operatively. If, however, one of the toe joints is involved in the fracture, leading to arthritis and symptomatic pain, Dr. Moon may recommend a fusion of the joint.
Causes
Foot fractures commonly occur as a result of a fall, motor vehicle accident, dropping a heavy object on the foot, or overuse. They can also occur after any increase in activity in patients with abnormally low bone density.
Symptoms
The common symptoms of a foot fracture include:
- Pain
- Bruising
- Tenderness
- Swelling
- Deformity
- Inability to bear weight
Diagnosis
A foot fracture is diagnosed by reviewing the patient’s medical history and performing a thorough physical examination of the foot. Imaging tests such as an X-ray, MRI, or CT scan may be ordered to confirm the diagnosis.
Navicular fractures can be especially difficult to diagnose without imaging tests.
Treatment
Treatment depends on the type of fracture sustained. The majority of forefoot fractures are mild and do not require surgery. Nonsurgical treatment includes rest, ice, compression, and elevation of the foot. Your provider may suggest a splint, cast, or boot immobilize the foot. For more severe fractures, surgery is usually required to align and reconstruct the affected bones or fuse the damaged joints. The surgical procedure may involve holding together bone fragments with plates and screws.
Physical therapy may be recommended to improve range of motion and strengthen the foot muscles. Weightbearing is usually a gradual process and is usually aided with the use of crutches and/or a walking boot or sandal.
Summary
Foot fractures are common injuries, making up about 10% of all orthopedic fractures. Foot fractures may be treated with conservative therapies or surgery depending on the severity. Because foot fractures can lead to serious complications and long-term disability if not properly treated, timely treatment is important.