Ankle fracture without dislocation

A significant proportion of lower limb injuries are to the bony structures of the distal tibia located on both sides of the ankle joint, i.e. Ankle fracture without bone displacement (when their physiologic position is not disturbed). [1]

Epidemiology

According to clinical observations, after fractures of the lower end of the radius in the wrist joint, ankle fractures are considered to be the most common. Thus, in one third of cases of serious ankle injuries, fractures of the outer or inner ankle are identified, and in about 20% of cases, both ankles are fractured.

But non-displaced fractures account for no more than 8-10% of cases.

Causes of the non-dislocated ankle fracture

As part of the ankle joint, which articulates the fibula and tibia, the ankles cover the articular surface of the talus of the foot (which is also part of the ankle) on both sides. The lateral or outer ankle (malleolus lateralis) is the protruding part of the epiphysis of the fibula, and the medial or inner ankle (malleolus medialis) is the protruding part of the epiphysis of the tibia.

See also - Anatomy of the ankle joint

Causes of ankle fractures include: injuries from falling or jumping from a height; tripping or slipping with the foot rolling up; impact in traffic accidents; sports injuries, including overuse and constant strain on the ankle, and most cases of exceeding the allowable range of motion of the joint: flexion-extension, extension-pronation, external rotation (pronation)-internal rotation (supination). [2]

Risk factors

Endogenous risk factors for ankle fracture, orthopedists include:

• overweight;
• metabolic disorders with calcium deficiency (reducing bone strength);
• osteoporosis and osteoarthritis;
• weakness of the ligaments, fascia and tendons of the ankle (including due to dystrophic disorders or connective tissue dysplasia), which leads to instability of the joint;
• history of pathologies of the musculoskeletal system and musculoskeletal apparatus.

And high-risk groups include athletes (who run, jump, or play soccer) and physically active people, as well as the elderly and postmenopausal women.

Pathogenesis

Ankle fractures associated with low-energy injuries are usually due to rotational displacement at the ankle joint.

The main mechanisms of fracture development when excessive force is applied to bone structures - their pathophysiology - are discussed in detail in the material: Fractures: general information [3]

Symptoms of the non-dislocated ankle fracture

With a fracture of this localization, the first signs are immediately manifested by intense pain in the ankle, as well as in the foot - with the inability to lean on the injured limb and walk. How much pain an ankle fracture without dislocation hurts depends on the traumatic factor and the type of fracture.

Other symptoms include ankle pain, gradually increasing extensive soft tissue swelling, hematoma formation, discoloration of the skin over the fracture, deformity and malposition of the foot (in the case of simultaneous ankle sprains). Hypothermia and partial numbness of the foot are also possible. [4]

Forms

Although there are several different classifications of ankle fractures in orthopedics and traumatology, the types of non-displaced ankle fractures most commonly noted by experts are:

• A pronation or pronation-abduction fracture that occurs when the foot is excessively deviated or abducted outward;
• supination-adduction fracture associated with foot adduction and inward rotation;
• A rotational fracture that occurs when the ankle joint and foot are abruptly rotated relative to their axis;
• isolated subsyndesmotic fracture of the lateral (external) ankle - below the distal junction of the fibula and tibia;
• Bimalleolar fracture - a fracture of the outer and inner ankles (which is often unstable - with ankle sprains).

Fracture of the external (lateral) ankle - a non-dislocated fracture of the right or left ankle is the most common type of ankle fracture that can occur when the foot is rolled or twisted; it also occurs when the fibula is fractured just above the ankle joint.

Such a fracture may be horizontal or oblique. Horizontal ankle fracture without displacement refers to pronation fractures, because the mechanism of traumatic injury is excessive rotation of the foot. And when the bone is broken at an angle, an oblique ankle fracture without displacement is defined, which is a consequence of longitudinally directed dynamic compression - when landing on the feet at an angle after a fall or jump, as well as at an oblique impact.

Apical fracture of the external ankle without displacement is also defined as a fracture of the top of the external ankle without displacement, in which, in cases of severe tipping of the foot, a small bone fragment detaches (peels off) from the top of the external ankle - at the site of attachment of the talofibular ligaments of the ankle joint.

A fall, ankle strike, or twisting of the foot or ankle can cause a marginal fracture of the lateral ankle without displacement (i.e., the lowest part of the epiphysis of the fibula is injured).

A medial (inner) ankle fracture is usually the result of a high-energy fall from a height. It may be combined with an ankle deltoid ligament injury and a tibial posterior fracture. [5]

Complications and consequences

The most likely complications and consequences of ankle fractures without bone displacement are as follows:

• nonunion or malunion;
• contracture (stiffness) of the ankle joint after immobilization;
• appearance of Zudek's syndrome, - swelling and severe pain in the ankle joint and foot;
• Development of post-traumatic ankle arthritis or foot neuropathy;
• pathologic changes in the periosteum - periostosis;
• post-traumatic flat feet.

Diagnostics of the non-dislocated ankle fracture

Diagnosis of ankle fracture begins with the collection of complaints and patient history, clarification of the circumstances of injury (to clarify the pathomechanism of injury) and physical examination of the injured limb.

Only instrumental diagnostics - X-ray of the ankle (in three projections), and if necessary - in cases of complex fractures - resort to computerized tomography allows to make an accurate diagnosis. [6]

Differential diagnosis

To exclude dislocation and subluxation of the ankle joint, synovitis, sprain or rupture of its ligaments, dislocation or fracture of the foot, fracture of the talus, differential diagnosis is carried out.

Treatment of the non-dislocated ankle fracture

Immobilization and pain management are mandatory components of fracture treatment, which is performed on an outpatient basis.

In case of sustained non-displaced fractures (mainly of the lateral ankle), conservative treatment is performed by applying a short plaster cast to the leg, an alternative to which is orthosis.

How long to wear a cast, the doctor decides after a control radiological examination (monitoring the dynamics of fracture healing), but the standard duration of immobilization is six to eight weeks.

Ice can be applied to the injured area to relieve pain, but painkillers are more commonly prescribed: NSAIDs like Ibuprofen and Orthofen (Diclofenac).

It is also recommended to take calcium preparations and vitamin D3 (which promotes the absorption of calcium and its deposition in bone tissue).

Ankle fractures without dislocation do not require surgical intervention. But in cases of unstable fracture of the lateral ankle (which is accompanied by stretching of the deltoid ligament of the ankle), surgical treatment may be required in the form of percutaneous osteosynthesis - fixation of bone structures with special rods, screws or metal plates. The same treatment method is used for most bimalleolar fractures. [7]

Rehabilitation and recovery

Injuries to the lower extremities are considered one of the most common causes of temporary disability, and sick leave for a non-displaced ankle fracture is granted for the period necessary for its treatment. How a non-displaced ankle fracture heals depends on the type and complexity of the fracture, as well as on the individual characteristics of the patient; in such a fracture, the average time of bone fusion (restoration of bone integrity) is from 2.5 to 4 months.

Rehabilitation of patients begins even before the cast is removed; these include various physiotherapeutic procedures (electrophoresis, etc.), as well as the first stage of physical therapy after ankle fracture without dislocation, during which it is necessary to move the fingers more often (to reduce swelling and activate blood circulation) and tone the muscles of the injured leg with static (isometric) loading - muscle tension at rest. In addition, in the absence of swelling and reduction of pain, the patient is allowed to gradually move, leaning on a cane, with maximum load on the healthy leg. The duration of such "walks" is gradually increased: from a few minutes to half an hour. [8]

After the cast is removed, the second stage of physical therapy begins, which includes both mechanotherapy, and exercises for ankle fracture without dislocation without load on the leg. For example, lying down (with the leg elevated), you should make rotational movements of the foot in different directions; in a sitting position, rotate the shin with the toes resting on the toes, roll the foot from the toes to the heel (or roll a small hard ball with the foot). [9]

At the third stage of LFC continues gymnastics after an ankle fracture without dislocation with more active movements, but with a dosed load (gradually increasing it). [10]

Prevention

Injury prevention and musculoskeletal strengthening play a major role in preventing ankle fractures.

Forecast

Proper treatment provides a favorable prognosis for this injury, and most people return to normal activities within four to five months after injury. But if an ankle fracture is not treated properly, it can lead to significant long-term complications and disability.