Fractures of the distal tibia and fibula may result in loss of stability of the ankle joint. They may present as a fracture only, a fracture and ligamentous injury, multiple fractures or a fracture dislocation.
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Summary
Fracture type | Management | Follow-up |
|---|---|---|
Isolated lateral malleolus | Weber A: walking cast or boot, weight-bearing as tolerated | Orthopaedic review in 7–10 days |
Weber B, undisplaced: short leg backslab, non-weight-bearing (NWB) | Orthopaedic review in 7–10 days | |
Weber B, displaced: short leg backslab, NWB | Orthopaedic review in ED or within 1–2 days | |
Weber C, ankle in normal anatomical position: short leg backslab, NWB | Orthopaedic review in ED or within 1–2 days | |
Weber C, talar shift or medial malleolar fracture: reduction, short leg backslab | Orthopaedic review in ED | |
Isolated medial malleolus | Undisplaced: non-urgent, short leg backslab, NWB | Orthopaedic review in 7–10 days |
Displaced: urgent, short leg backslab, NWB | Orthopaedic review in 7–10 days | |
Bimalleolar and trimalleolar | Reduction if required, short leg backslab, NWB | Orthopaedic review in ED |
Posterior malleolus | Undisplaced: short leg backslab, NWB | Orthopaedic review 7–10 days |
Displaced >25% of articular surface: short leg backslab, NWB; may require open reduction internal fixation (ORIF) | Orthopaedic review either in ED or within 1–3 days | |
Fracture dislocation | Reduction, short leg backslab. Requires ORIF | Orthopaedic review in ED |
Open fractures | Wound cleaned Manage based on fracture type | Orthopaedic review in ED |
Classification
Weber classification
Based on the position of the fibular fracture. Higher risk of syndesmotic disruption and instability is associated with more proximal fractures.
- A fibular fracture below the level of the syndesmosis. Mechanism is supination of the foot.
- A fracture at or near the level of the syndesmosis. Mechanism is external rotation of the foot. May be associated with medial ankle injury, fracture or posterior malleolus fractures.
- A fracture above the level of the syndesmosis. Causes disruption of the syndesmosis and is usually associated with medial ankle injuries. This type of injury includes Maisonneuve injuries.
Lauge-Hansen classification
Based on foot position at time of injury and the force applied through the foot.
- Supination-adduction
- Supination-external rotation
- Pronation-abduction
- Pronation-external rotation
Anatomical classification
- Isolated lateral malleolus
- Isolated medial malleolus
- Bimalleolar
- Trimalleolar
- Fracture and/or dislocation
Presentation
Presentation may vary between patients. From weight-bearing with an antalgic gait to NWB with significant pain, swelling, discomfort and varying deformity.
Neurovascular status should be carefully examined.
The skin should be assessed for any open injuries and the amount of soft tissue swelling.
Dislocations should be reduced and casted immediately.
The patient should be assessed for:
- swelling
- deformity
- open injuries
- site of tenderness (palpate entire length of fibula)
- other injuries
- time since injury
- weight-bearing status
- neurovascular status
- related past medical history.
Imaging
X-ray: AP, lateral and mortice views.
Management, referral and follow-up
- Fracture dislocations should be reduced.
- Open wounds should be cleaned and dressed in a sterile manner.
- The leg should be elevated.
Management
The stability of a fibula fracture determines treatment. Fractures distal to the syndesmosis are unlikely to be associated with ligamentous injury and therefore likely to be stable.
Fibula fractures that are associated with medial fractures or medial ligamentous injury are likely to be unstable despite normal alignment on x-ray. Talar shift or widening of the mortice indicates instability.
Fractures below the syndesmosis (Weber A avulsion type injuries) without associated medial ankle fracture and/or tenderness can be treated in a walking or cam boot and may mobilise weight bearing as tolerated.
Isolated fibular fractures at the level of the syndesmosis (Weber B) without associated medial injury should be placed in a short leg backslab (ankle at plantargrade) and remain NWB.
Fractures above the syndesmosis (Weber C) involve disruption of the syndesmosis and are usually associated with medial ankle injury. These fractures should be placed in a short leg backslab and remain NWB.
Fibular fractures which are displaced >3mm and have associated medial malleolar fracture or medial ligament injury are unstable and require orthopaedic review. A short leg backslab, ankle at plantargrade, should be applied. NWB mobility.
Referral urgency
Undisplaced: non-urgent
Displaced: urgent
Follow-up
Undisplaced: orthopaedic review in 7–10 days
Displaced: orthopaedic review in ED or within 1–2 days.
Management
With medial malleolus fractures, care should be taken to rule out any other fracture or injury around the ankle. The entire length of the fibula should be palpated and x-rayed to rule out any Maisonneurve type injuries. Concomitant fracture, ligament injury or talar shift indicates the fracture is likely to be unstable and should be reviewed by orthopaedics.
If medial malleolar injury is truly isolated, then a short leg backslab should be applied and the patient is to remain NWB until orthopaedic review.
Referral urgency
Undisplaced: non-urgent
Displaced: urgent
Follow-up
Undisplaced: orthopaedic review in 7–10 days
Displaced: orthopaedic review in ED or within 1–2 days
Management
These fractures are unstable and require ORIF.
A short leg backslab should be applied.
NWB.
Referral urgency
Urgent
Follow-up
Orthopaedic review in ED
Management
As with medial malleolar fractures, care should be taken to rule out any other injury around the ankle which would indicate instability.
Fractures which involve >25% of the articular surface or are displaced >2mm usually require an ORIF. CT is the best way to determine articular displacement.
A short leg backslab with NWB mobility should be applied to all posterior malleolus fractures.
Referral urgency
Displaced: urgent
Undisplaced: non-urgent
Follow-up
Displaced: orthopaedic review either in ED or within 1–2 days
Undisplaced: orthopaedic review in 7–10 days
Management
Reduction, short leg backslab, elevate
Requires orthopaedic review and ORIF
NWB
Referral urgency
Urgent
Follow-up
Orthopaedic review in ED
Management
Clean and dress wound, short leg backslab.
Orthopaedic review.
Referral urgency
Urgent
Follow-up
Orthopaedic review in ED
Potential complications
Non-union is rare. Malunion may occur with:
- a lateral malleolus fracture that is shortened or rotated
- a displaced posterior medial malleolus fracture, or
- a talar shift.
Arthritic changes can occur due to damage at time of injury or malunion.
Patient advice
- Pain from the fracture and restriction of movement is usual for 2–3 weeks and will require regular analgesia initially, then as required.
- Monitor for compartment syndrome.
Care of temporary casts fact sheet
Background
The ankle joint (talocrural joint) is a synovial hinge type joint. It is formed by the fibula, tibia and talus. The distal ends of the fibula and tibia form a socket known as the mortise in which the talus sits. A complex series of ligaments support the joint. The main movements of the joint are plantarflexion and dorsiflexion. In plantarflexion it is possible for some rotation, abduction and adduction movements. The joint is more stable in dorsiflexion than plantarflexion.
Resources
- Ankle fractures
Source: Orthobullets
- Ankle fractures in adults ( NSW Health login required)
Source: UpToDate - Koval K, Zuckerman J. Handbook of fractures. Philadelphia: Lippincott Williams and Wilkins; 2002.
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/distal-tibia-fibula