Trauma & Orthopaedics

Ankle Fracture

Ankle-fracture management is driven by skin and neurovascular status, mortise stability and patient factors: urgent reduction for deformity, appropriate radiographs and CT for complex patterns, weight-bearing treatment for stable injuries, and timely fixation or specialist non-operative care for unstable injuries.

In a nutshell

An ankle fracture is managed by stability and soft-tissue/neurovascular status, not by the fracture label alone. Use the Ottawa ankle rules and appropriate radiographs, reduce deformity urgently, confirm the post-reduction position, allow early weight-bearing for stable unimalleolar injuries, and refer unstable or displaced mortise injuries for fixation or specialist non-operative management.

Classic presentation

Painful swollen ankle after twisting trauma, with malleolar tenderness, reduced weight-bearing and sometimes deformity or talar shift.

Key points

Assess and document skin, pulses, sensation and motor function before and after reduction.
Use Ottawa ankle and foot rules for people over 5 years to decide whether X-ray is needed, but do not let the rule delay emergency reduction.
Ankle radiographs should include a true lateral and mortise view; image the whole leg if proximal fibular tenderness suggests Maisonneuve injury.
CT is selective: use it for complex or posterior malleolar patterns and operative planning.
Stable non-surgical unimalleolar fractures should usually be allowed immediate unrestricted weight-bearing as tolerated; uncertain stability needs review and radiographs within 2 weeks.
Unstable mortise, talar shift, significant bimalleolar/trimalleolar or syndesmotic injury generally needs reduction and fixation planning; NICE advises considering surgery on the day of injury or next day.
Repeat neurovascular examination and post-reduction X-rays must be documented before ED transfer.
Open fracture, arterial compromise, compartment syndrome and severe soft-tissue compromise require emergency complex-trauma pathways.

First-line investigation

Ottawa ankle and foot rules followed by ankle radiographs with true lateral and mortise views; add whole-leg films or CT when the examination or fracture pattern requires it.

Management

Protect the limb and reduce deformity

Document skin and neurovascular status, provide analgesia and splinting, urgently reduce gross deformity or threatened skin, then repeat neurovascular assessment and obtain post-reduction radiographs.^1,4

Image and determine stability

Use Ottawa ankle/foot rules, true lateral and mortise radiographs, whole-leg imaging for suspected Maisonneuve injury and selective CT for complex or posterior malleolar patterns.^2,1

Mobilise safely and reduce secondary risk

Give clear weight-bearing, elevation, cast/splint, thromboprophylaxis, rehabilitation, driving and return-precaution advice, individualised for fracture stability, fixation, soft tissues, neuropathy and comorbidity.^1,8,6

Maintain mortise alignment

Allow stable non-surgical unimalleolar injuries to weight-bear as tolerated; refer unstable or displaced mortise injuries for timely fixation or selected close-contact casting when reduction can be maintained.^2,1

Confirm healing and function

Review uncertain stability within 2 weeks, and after surgery within 6 weeks with imaging and rehabilitation planning; advise patients how to self-refer if pain, deformity, neurovascular symptoms or function are not improving.^2,1

Exam traps

Weber C does not automatically mean surgery and Weber B does not automatically mean stability; assess the mortise and whole injury pattern.
Do not wait for CT or definitive imaging before reducing a deformed, threatened or neurovascularly compromised ankle.
A stable unimalleolar fracture is not automatically non-weight-bearing: NICE recommends immediate unrestricted weight-bearing as tolerated for non-surgical management.
A negative Ottawa rule does not override an unreliable examination, gross deformity, open injury or neurovascular emergency.
Do not treat an open fracture or suspected Maisonneuve injury as a simple isolated closed lateral-malleolus fracture.

Illustrations

Ankle mortise anatomyDiagram of the talus within the mortise formed by the tibial plafond, medial malleolus and lateral malleolus, stabilised by the syndesmosis and supporting ligaments.PassFinals · original

Weber classification of fibular fracturesIllustration comparing Weber A, B and C fibular fracture levels relative to the syndesmosis, with a reminder that stability depends on the whole mortise.PassFinals · original

Stress ankle X-ray showing talar shiftStress radiograph demonstrating a distal fibular fracture with medial clear-space widening and lateral talar shift, indicating an unstable ankle mortise.Dr Maulik S Patel, Radiopaedia.org, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.