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Person sitting down in pain with arms around Knee from ACL pain

Ankle Fracture

 

What causes ankle fractures?

Typically, ankle fracture occurs post-trauma such as falls onto feet from high ground, motor vehicle accidents and sporting settings that involve twisting motions of the ankle in a closed chain position (L Holloway, 2014). Bone displacement can occur depending on the mechanism of injury as well as the force from the impact. Bone mineral density (BMD) also plays a role in the incidence of ankle fractures, as bones with lessened mineral density tend to break easier. Therefore, pathologies that affect BMD such as T2DM and Osteoporosis greatly increase the risk of fractures (Thur et al., 2012).

Ankle fracture classification:

 Weber:

Weber classification Is determined based on position of the fracture:

Type A – Below the level of the tibial plafond (syndesmosis)

Type B- fracture at the level of the tibial plafond (syndesmosis)

Type C- fracture proximal to the level of the tibial plafond and often have an associated syndesmotic injury

(Kennedy et al., 1998)

Lounge-Hansin

Lounge-Hansin classification are based on the mechanism of injury:

Type 1- Supernation/ Adduction of the ankle.

Type 2- Supernation and External Rotation of the ankle.

Type 3 – Pronation and external rotation of the ankle (Tartaglione et al 2015)

Common symptoms / signs

Subjective:

  • Acute trauma
  • Sporting- landing on ankle with external rotation of the tibia/fibula

Reports a cracking sound

Pain on weight bearing.

Objective:

Use the OTTOWA ankle rules to confirm if x-ray is necessary (Beckenkamp et al., 2017).

Imaging is required to confirm ankle fractures.

Aggravators:

– Weight bearing: During the inflammatory process immediately post fractures, several inflammatory mediators are release which active and sensitive free nerve ending, signalling the pain inhibition afferent and reflex pathways to the brain(Alves et al., 2016).

Eases:

– Pain medications

– Ice Therapy 

Common Differential Diagnosis:

  • Syndesmosis injury
  • DVT
  • Lateral Ankle Sprain++ (occurs commonly together)
  • Sinus tarsi syndrome
  • Posterior and anterior ankle impingement
  • Fibularis tendinopathy
  • Rheumatoid athirst
  • Ankle dislocation

Risk factors

  • Female >50 years old
  • PMHx ankle #
  • High BMI
  • multiple medication
  • Smoking
  • Dx of osteoporosis.

(L Holloway, 2014)

How is it treated?

Acute phase:

Immediately post-fracture, the body’s inflammatory process begins to invade the affected area. This along with vessel ruptures around the bone causes significant swelling. Unlike other injuries swelling and inflammation provides a basic frame for subsequent healing (Sheen et al., 2022), therefore anti-inflammatory medication is contraindicated. Depending on how much bone displacement is present, surgery may be required to insert an open reduction internal fixation (ORIF) to stabilise the ankle joint and increase the chance of union. If surgery is not required, a plaster cast will be applied and non-weight bearing status is applied for at least 5-6 weeks, followed by a CAM boot and Partial WB for the next 2-4 weeks. If different to that of regular management, always follow the post-operative orders set by the orthopaedic surgeon. During the first 6-8 weeks, a soft cartilaginous bone structure is formed to re-join the bones, however, this is by no means strong enough to hold the weight of an individual and will only enlarge with more movement and load, hence why a non-weight bearing status is given (Sheen et al., 2022). Therefore, Gait aids (forearms crutches) should be prescribed for no weight-bearing timeframe and education should be given by the physiotherapist about how to ambulate, if not done so already in a hospital.

Exercise during the non-weight bearing stage comprises knee and hip dominant open chain exercises. This is to ensure limited muscle atrophy loss of the effective limb, without placing load through the ankle complex, inhibiting the healing process (DiFonzo & Bordia, 2008). Examples of exercises are Prone hip extension, knee extensions and hamstring curls, all and which can progress using a TheraBand.

Only once this soft cartilaginous bone forms into harder, regular bone approximately 8-10 weeks post-fracture, will it be able to withstand some load from body weight. When the partial weight-bearing status is given, some ankle mobilisation treatment should be conducted to improve the range of motion through the joint. Reduced ROM in a joint is limited by pain or stiffness such as inflammation that may restrict normal fluency of the joint range. To combat this, the physiotherapist should use talocrural and subtalar mobilisations as well as prescribe AAROM (Lin et al., 2012) (such as dorsiflexion with a TheraBand) exercise to regain ROM post immobilization. Additionally, Foot intrinsic exercises such as towel scrunches should be prescribed post cast removal.

Sub-Acute:

Once X-Rays have established the correct union of the affected bones in the ankle LL Strength and balance exercises for the anterior, posterior, and lateral compartment muscles of the lower leg should be prescribed. These are to build muscle and tendon tolerance before introducing more explosive and high-impact exercises later in rehabilitation. Failure to do this and implement plyometrics early in rehab may result in tendinopathy or tendinitis of these muscles. Running at short distances and at a slow pace should be introduced in this phase of rehab.

When ready, the clients should be introduced to higher impact loads such as jumping, multi-directional hopping and external perturbation input landing, ensuring the client is returning to sport. Sport-specific exercise should be introduced as the final stage of rehab to ultimately determine if the client has built enough bony and muscular tolerance to RTS. The intensity of this later-stage rehab may be regressed if the client does not require such high impact tolerance for the ADLs and therefore may be discharged earlier.

 

References:

Alves, C. J., Neto, E., Sousa, D. M., Leitão, L., Vasconcelos, D. M., Ribeiro-Silva, M., Alencastre, I. S., & Lamghari, M. (2016). Fracture pain-Traveling unknown pathways. Bone, 85, 107–114. https://doi.org/10.1016/J.BONE.2016.01.026

Beckenkamp, P. R., Lin, C. W. C., Macaskill, P., Michaleff, Z. A., Maher, C. G., & Moseley, A. M. (2017). Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: A systematic review with meta-analysis. British Journal of Sports Medicine, 51(6), 504–510. https://doi.org/10.1136/bjsports-2016-096858

DiFonzo, N., & Bordia, P. (2008). Effecrts of rehabiliation after ankle fracture; a cochrane systematic review. Journal of Allergy and Clinical Immunology, 130(2), 556. http://dx.doi.org/10.1016/j.jaci.2012.05.050

Kennedy, J. G., Johnson, S. M., Collins, A. L., Dallo Vedova, P., McManus, W. F., Hynes, D. M., Walsh, M. G., & Stephens, M. M. (1998). An evaluation of the Weber classification of ankle fractures. Injury, 29(8), 577–580. https://doi.org/10.1016/S0020-1383(98)00116-8

L Holloway, K. (2014). Foot and Ankle Fracture Incidence in South-Eastern Australia: An Epidemiological Study. Clinical Research on Foot & Ankle, 02(04). https://doi.org/10.4172/2329-910x.1000148

Lin, C. W. C., Moseley, A. M., & Refshauge, K. M. (2012). Rehabilitation for ankle fractures in adults. Cochrane Database of Systematic Reviews, 3, 1–54. https://doi.org/10.1002/14651858.CD005595.pub2

Sheen, J. R., Garla, V. V, & Hospital, T. (2022). Fracture Healing Overview. 11–14.

Thur, C. K., Edgren, G., Jansson, K. Å., & Wretenberg, P. (2012). Epidemiology of adult ankle fractures in Sweden between 1987 and 2004. Acta Orthopaedica, 83(3), 276–281. https://doi.org/10.3109/17453674.2012.672091

 

 

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