Ankle Injuries

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 26 – Ankle Injuries

Ankle Injuries
I. Ankle Sprains
The approach to ankle sprains should distinguish between the acute and chronic ankle sprain. The most common ankle sprain
consists of an inversion injury of the foot with some degree of plantar
flexion. Overall, the period of recovery is relatively short and
uneventful. A more relevant injury with a completely different period
of recovery is the injury while the foot is in eversion, the so-called “high ankle sprain.” It accounts for 1% to 15% of the total ankle sprains (1).
Therefore, the first issue when approaching a patient with an ankle
sprain should be directed to identifying the mechanism of injury. Given
the frequency of fractures, it is often recommended to obtain the
history and do a brief exam using only palpation, and, if suspicion for
a fracture is present, then obtain x-rays prior to extensive physical
examination techniques.
  • Acute presentation
    • Inversion injuries.
      With inversion ligamentous injuries, there is tearing of the lateral
      ligaments in order from front to back. Thus, the anterior talofibular
      ligament (ATFL) is the most commonly injured ligament followed by the
      calcaneofibular ligament (CFL) and, in very rare instances, the
      posterior talofibular ligament (PTFL).
      Fig. 26-1
      shows the anatomic location of the ligaments. Fractures can occur with
      simple inversion injuries. The most common sites are the distal fibula
      and the base of the fifth metatarsal.
      • Examination.
        Palpation is the key to examining ankle injuries. Included in this is
        palpation of the bones around the ankle. Special attention should be
        drawn to the distal fibula, distal tibia, and the base of the fifth
        metatarsal as per the Ottawa criteria (Table 26-1).
        In more severe fractures, also palpate the proximal fibula as this can
        be broken (Maissoneuve fracture). All ankle ligaments should be
        palpated looking for tenderness. In the acute setting, pain is quite
        limiting; therefore, it is very difficult to stress the ankle joint or
        obtain ankle stress radiographs to confirm which ligaments are intact.
        In the absence of fracture, soft tissue swelling and pain will dictate
        the treatment.
      • Radiographic imaging. The need for x-rays can be guided by consideration of the Ottawa ankle rules (Table 26-1).
        It is important to note that the rules do not apply to a pediatric
        population with open growth plates (to be safe, it is recommended to
        x-ray those under age 18). Although not specifically listed, we
        recommend strong consideration to obtain x-rays on people over the age
        of 50, especially women over the age of 50 due to lower bone mass and
        subsequent higher fracture rates. X-rays should include anteroposterior
        (AP), lateral, and mortise views.
      • Treatment. If there is no medial tenderness, the ankle joint should be considered a stable joint.
        The traditional principles of rest, immobilization, compression,
        elevation, and icing should be applied followed by a functional return
        to activities while protected with any of the commercially available
        ankle braces until the pain allows proper muscle contraction of the
        dynamic stabilizers of the ankle (peroneal and deep compartment muscles
        of the lower leg). In rare occasions, due to pain with weight bearing,
        the patient will have to be protected for 6 to 8 weeks.
        If there is medial or anterior capsule tenderness, the possibility of developing talar instability is higher, and closer examination of the ankle



        mortise for talar dome injuries and symmetry is warranted. If
        suspected, the period of immobilization in a walking cast or boot
        should be longer, for 6 to 8 weeks until the medial and anterior
        tenderness disappear. At that time it can be treated as a stable injury
        depending on the remaining discomfort within the ankle joint.

        Figure 26-1. Anatomic description of the most significant ligaments and bones of the ankle and midfoot area.
        TABLE 26-1 Ottawa Criteria to Perform Radiographic Examination
        Ankle injuries

        1. Pain along the posterior margin of the most distal 6 cm of the fibula
        2. Pain along the posterior margin of the medial malleolus
        3. Unable to bear weight immediately after the injury or to take four steps in the Emergency Department (even with a limp)
        4. Age less than 18
        Midfoot injuries

        1. Pain along the base of the fifth metatarsal
        2. Pain along the navicular
        3. Unable to bear weight immediately after the injury or to take four steps in the Emergency Department (even with a limp)
        4. Age less than 18
    • Eversion injuries
      • Examination.
        The exam will show some tenderness along the most anterior and distal
        aspect of the syndesmosis of the ankle. Some tenderness along the
        lateral ligament complex may be present although to a much lesser
        degree than with true inversion ankle sprains. Any degree of external
        rotation, which stresses the ankle mortise, will increase or reproduce
        the pain. The external rotation can be applied directly by the examiner
        holding the lower leg with one hand and torquing on the foot with the
        opposite hand while keeping the ankle in a neutral position, so the
        talus is locked in the ankle mortise. If a fracture has been ruled out,
        a “squeeze test” (using both hands to push the mid-fibula and tibia
        together, noting pain distal to the area of compression) can be
        performed to assess syndesmotic injuries. If the patient can tolerate
        weight bearing, a more sensitive test for a syndesmosis injury consists
        of standing on the injured leg and applying an external rotation force
        to the ankle with an internal turn of the pelvis with the knee fully
        extended. If the patient can stand and perform some degree of external
        rotation, the suspicion for an unstable mortise should be low. If there
        is any tenderness in the proximal lower leg, full length tibia and
        fibula radiographs should be obtained to rule out a proximal fibula
        fracture (Maissonneuve fracture) or an unstable syndesmosis. This
        projection is taken as an AP view with 30° of internal rotation (when
        both malleolus are equidistant from the x-ray beam). A noncompetent
        syndesmosis is defined as the one that presents on an AP view of the
        ankle more than 6 mm of clear space between the tibia and the fibula
        measured at 10 mm proximal from the joint line (2) (Fig. 26-2).
        When it comes to x-ray measurements, the clear space in between the
        tibia and the fibula has been shown to be more reliable and less
        subjective to rotation than the overlap in between the tibia and fibula
        (<5 mm). If the syndesmosis appears intact on a static radiograph,
        but suspicion for syndesmotic injury remains high, consider stress
        views of the ankle (ideally under fluoroscopic dynamic examination)
        while applying external rotation to the foot. The best projection to
        assess the stability of the syndesmosis is the mortise view. The
        patient will have to be either sedated or injected with local
        anesthetic along the syndesmosis prior to its


        A total of 5 to 15 cc of lidocaine 1% with epinephrine should suffice
        to anesthetize the syndesmosis. The injection is performed using a 25-
        or 22-gauge needle along the anterior aspect of the syndesmosis,
        starting immediately proximal to the joint line level and always
        “walking” along the lateral cortex of the tibia from distal to
        proximal. Special attention has to be paid to not angle the needle too
        posteriorly, never posterior to the plane of the fibula, to avoid
        damage into vital structures of the posterior compartment of the leg.

        Figure 26-2. Radiographic appearance of the most common bony landmarks of the ankle and foot. A: Medial view of ankle region. B: Anterior view of ankle. C: Mortise view of ankle region. D:
        Lateral view of foot. M, medial malleolus; L, lateral malleolus; T,
        talus; Ca, calcaneus; S, sustentaculum tali; N, navicular; Cu,
        cuneiforms; Cb, cuboid; Mt, metatarsal; ST, sinus tarsi; A Achilles
        tendon; F, fat; arrowhead, superimposed tibia and fibula; Syn,
        Syndesmosis; FHL, flexor hallucis longus; EM, extensor muscles; CS,
        tibiofibular clear space; OL, tibiofibular overlap.
      • Treatment. If


        the syndesmosis is stable
        or in the absence of fractures, the patient should be immobilized in a
        walking cast or boot for 6 to 8 weeks followed by a functional return
        to activities of daily living and sports. If the syndesmosis is unstable
        or in the presence of a proximal fibula fracture, the patient will
        require fixation of the syndesmosis with screws followed by
        immobilization for 6 to 8 weeks. Weight bearing should be started prior
        to removal of the screws and always after warning the patient about the
        possibility of screw breakage. A residual wide syndesmosis because of a
        misdiagnosis or improper treatment is a devastating sequelae that will
        lead to a very severe post-traumatic osteoarthritis of the ankle joint
        within 1 to 2 years.

  • Subacute-chronic presentation
    • Inversion injuries.
      The patient presents with some residual discomfort in areas where there
      may still be some healing taking place or where an injury has been
      missed. The physician has to rule out any residual instability,
      reported to be present in 20% to 40% of ankle sprains, or a chondral
      injury of the talus, present in 6.5% of ankle sprains (3).
      If the patient continues to report instability after a period of
      physical therapy, then one should consider stress views of the ankle.
      If the patient still presents enough pain that the ankle will be
      protected by contraction of the surrounding musculature, therefore
      making the exam for stability unreliable, the patient should have some
      intravenous sedation or local anesthetic injected into the ankle. A
      total of 5 cc of lidocaine 2% with epinephrine should be enough to
      anesthetize the ankle joint. The injection is performed with a 25- or
      22-gauge needle along the most medial border of the ankle joint
      immediately distal to the medial shoulder of the tibial plafond and
      medial to the anterior tibialis tendon. The needle has to be angled at
      45° from the coronal plane. The ankle can also be approached through
      the lateral aspect over the “soft spot,”
      which is defined as the junction of the tibia and fibula at the level
      of the joint line. However, the chances of damaging the dorsal
      cutaneous branch from the superficial peroneal nerve are relatively
      high. The best chance to identify the nerve branch is with gentle
      palpation of the skin, looking for a cord-like structure when the
      fourth toe is forced into plantar flexion.
      The stress views are obtained with a lateral radiograph
      while the foot is pulled forward (an anterior drawer test) in slight
      plantar flexion. The most commonly injured ligament, the ATFL, is
      stressed during this maneuver. A 10-mm difference of anterior
      displacement between the stress view and the resting view or a 3-mm
      difference of anterior displacement compared to the stressed opposite
      side is indicative of ankle instability. Treatment options for chronic
      instability include a formal physiotherapy program and, if that fails,
      the next reasonable step is a surgical repair/reconstruction of the
      lateral ligament complex of the ankle. In the absence of an obvious
      chondral injury of the talus on plain x-rays, a magnetic resonance
      imaging (MRI) scan is necessary to rule it out. A symptomatic chondral
      injury most likely will require some surgical treatment (i.e.,
      arthroscopic debridement +/- subchondral drilling) to improve the
    • Eversion injuries.
      The most common reason to present with residual pain after a
      syndesmosis sprain will be some degree of remaining instability. A
      careful and detailed evaluation of the patient has to be performed as
      surgical fixation of the syndesmosis will be the most likely treatment
II. Ankle Fractures
  • Classification.
    Ankle fractures are intraarticular injuries, and accurate reduction as
    well as maintenance of the reduction is required for a satisfactory
    long-term result. To achieve reduction by closed manipulation, it is
    necessary to know the direction of the forces producing the fractures.
    It must be emphasized that fractures about the ankle usually are not
    isolated injuries but have significant associated ligamentous ruptures.
    Ankle fractures may be classified by the Lauge-Hansen scheme (Fig. 26-3).
    This classification is useful because of the method used for its
    description. The first term makes reference to the position of the foot
    at the time of injury and the second term to the direction of the force
    applied to produce the fracture. That information is extremely valuable
    in planning closed reduction maneuvers.
    Figure 26-3. The Lauge-Hansen classification of ankle fractures. A:
    The supination-eversion fracture. Stage I: The avulsion of the anterior
    talofibular ligament from the tibia or simple rupture of the ligament.
    Stage II: The classic oblique fracture of the distal fibula, beginning
    anteriorly at the joint line and extending obliquely and posteriorly
    toward the shaft of the bone. Stage III: Avulsion or rupture of the
    posterior tibiofibular ligament. Stage IV: Avulsion fracture of the
    medial malleolus. B: The
    supination-adduction fracture. Stage I: Avulsion of the tip of the
    lateral malleolus or rupture of the associated ligaments. Stage II:
    Vertical fracture of the medial malleolus, usually beginning at the
    plafond. C: The pronation-eversion
    fracture. Stage I: Avulsion of the medial malleolus or ruptured deltoid
    ligament. Stage II: Rupture or avulsion of the anterior tibiofibular
    ligament. Stage III: A high short oblique fracture of the fibula. Stage
    IV: A posterior lip fracture of the tibia. D:
    The pronation-abduction fracture. Stage I: Avulsion of the medial
    malleolus or ruptured deltoid ligament. Stage II: Rupture or avulsion
    of the syndesmotic ligaments. Stage III: A short, oblique fracture of
    the distal fibula at about the level of the ankle joint. (From Weber
    MJ. Ankle fractures and dislocations. In: Chapman MW, Madison M, eds. Operative orthopaedics, 2nd ed. Philadelphia, PA: JB Lippincott, 1993:731–745, with permission).


    The Danis-Weber or AO Association of Osteosynthesis classification system concentrates on the pattern of the fibular fracture (Fig. 26-4).
    The type A fracture is distal to the level of the syndesmosis and
    frequently transverse, the type B fracture is a spiral oblique fracture
    at the level of the syndesmosis, and the type C fracture is proximal to
    the syndesmosis level.
  • Examination. The ankle has to be palpated for tender areas. The Ottawa Criteria (Table 26-1)
    for evaluation and management of ankle injuries have been proven to be
    a practical way to approach these injuries. Recently, it has been shown
    to have a sensitivity of no less than 99.6% for detecting fractures (4).
    However, in spite of these reports, it does not seem to be used
    routinely for fear of missing ankle fractures and the potential legal
    consequences associated. The lack of soft tissue swelling in some
    situations may be misleading, especially in the elderly population.
  • Radiographs.
    AP, lateral, and oblique (the mortise view) films are essential for
    evaluating any ankle injury. A clearer delineation of the medial
    malleolar fracture may be achieved by an additional view obtained with
    the foot in 45 degrees of internal rotation. A lateral radiograph
    obtained at 50 degrees of external rotation is the best way to
    visualize the posterior malleolus (5).
  • Treatment. The main feature that determines the treatment plan is if the ankle fracture is a stable or unstable injury.
    • Stable injuries.
      A stable ankle fracture is defined as the one that presents no widening
      of the medial or lateral mortise joint space. A fracture distal to the


      with a ruptured deltoid ligament, which is suspected if there is
      significant medial tenderness, will represent an unstable ankle
      fracture with a stable syndesmosis. Therefore, the definition of
      stability should be an ankle joint where the fracture is distal to the
      syndesmosis with no injury to the medial stabilizers and consequently
      with no widening of the medial mortise. The immediate treatment
      consists of elevation, reduction of the fracture, and immobilization as
      soon as possible to reduce soft tissue swelling. If the fracture is
      merely a small avulsion off of the distal tip of the fibula without any
      involvement of the mortise, then treatment can be similar to that of
      the associated ligament sprain. For stable fractures that are larger
      and with some degree of displacement, a closed reduction maneuver can
      be attempted. For most oblique fractures of the fibula, the reduction
      is via plantar flexion and internal rotation. This can often be
      achieved by lifting the patient’s limb (with the patient in the supine
      position) by the great toe. Immobilize the patient’s leg in a


      leg splint in this position. For long-term treatment (more than 4–6
      weeks), the ankle must be maintained in a neutral position (90° from
      the long axis of the lower leg) to prevent any Achilles contracture and
      a longer than expected recovery time. The patient should be instructed
      in toe-touch weight bearing until there are radiographic signs of
      callus and lack of tenderness to pressure (3–4 weeks) over the lateral
      malleolus. Further protect the injury in a short leg cast with the foot
      in neutral position for another 3 to 4 weeks. Stable ankle fractures
      have equivalent results whether treated operatively or nonoperatively (6). Consequently, we recommend an attempt at nonoperative treatment whenever possible.

      Figure 26-4. Diagrammatic representation of the Danis-Weber classification system. A: Transverse fracture of the distal malleolus. B: Spiral fracture at the level of the mortise. C: Fractures above the mortise with disruption of the syndesmosis. (From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven, 1993: 340.)
    • Unstable injuries
      • These fractures should be reduced and internally fixed as an urgent procedure if the patient is seen before significant swelling is apparent (7,8).
        Preoperative planning is essential to minimize soft-tissue stripping
        and maximize fixation. Patients with open fractures should be managed
        with wound debridement and internal fixation; the results are generally
        equivalent to those for closed fractures (9). Significant improvement can be expected to continue 6 months after the fracture occurred (10,11).
        • Medial malleolar fragments
          should be reattached with screws for larger fragments and with
          Kirschner wires with supplemental tension band wires for smaller
          fragments. With screw fixation, a length of 35 to 40 mm is appropriate
          so that the metaphyseal bone is engaged and the medullary canal is
          avoided with loss of screw purchase. The rate of nonunion with surgical
          treatment is reported to be as low as 1% compared with 15% with
          conservative treatment (12).
        • Posterior malleolar fragments
          are stabilized with screw fixation if they involve more than one fourth
          of the articular surface. Generally these fragments are reduced by
          reduction of the associated distal fibula fracture. The lag screw
          placement can be done from the anterior to posterior direction
          (frequently percutaneously). Formal open reduction, if required, must
          be done before definitive fixation of the lateral malleolus, which may
          limit the surgical exposure; the incision must be well posterior to the
        • Lateral malleolar fractures
          below the ankle joint (Danis-Weber A) may be reduced as medial
          malleolar fractures. If possible, an attempt should first be made to
          reduce and fix the fracture with a lag screw. Fractures with disruption
          of both anterior and posterior tibio-fibular ligaments can be held with
          a “position” (or syndesmosis) screw inserted parallel to the plafond
          into the tibia. This screw is generally placed after anatomic reduction
          of a type B or C fibula fracture, with the foot fully dorsiflexed (to
          prevent narrowing of the ankle mortise), through the plate, and after
          gaining purchase on one or both of the tibial cortices (see iv
          below). Spiral or oblique fractures with the tibio-fibular ligament
          intact may be reapproximated by oblique lag screws and/or with a small,
          one-third tubular plate. Prophylactic antibiotics should be utilized (13).
          These plates could be placed on the posterior aspect of the fibula to
          prevent irritation from the plate when in the lateral aspect, a more
          subcutaneous position (14). More recently, success has been achieved with bioabsorbable implants (15,16). Repair to the deltoid ligament avulsion is generally not necessary (17).
          Postoperatively, the leg may be treated in a short-leg compression
          dressing with a plaster or fiberglass splint to control the position of
          the foot. As soon as the swelling is controlled, at 5 to 7 days, a
          removable splint can be used and early active motion started. The
          patient should remain partial weight bearing for 4 to 6 weeks. If the
          patient is unable to co-operate with the early, active range-of-motion
          protocol, then a short-leg cast is applied for 4 to 6 weeks (18,19). Weight bearing and strengthening exercises are initiated following this period.
        • P.379

        • iv. If the tibio-fibular syndesmosis is widened,
          it is because the distal interosseous membrane is torn. This injury can
          be associated with a proximal fibula fracture (the Maissoneuve
          fracture). Authorities who report the best results treat this injury
          with a suture repair of a ligamentous rupture when feasible and with
          one or two position (or syndesmosis) screws placed parallel to the
          plafond. Some authors recommend the use of 4.5-mm cortical screws; we
          favor the use of one or two 3.5-mm screws with purchase through four
          cortices (exit the tibia slightly to allow removal if they break). Care
          must be taken to maintain the normal fibular length and, by keeping the
          foot in neutral position, the proper mortise width. Some authorities
          recommend delaying full weight bearing until the syndesmosis screws are
          removed. However, the authors have seen many more problems following
          early removal of the syndesmosis screws, and, currently, it is
          recommended to leave them in as weight bearing is progressed. The
          patient should be advised that the screws may break.
      • When swelling is already significant,
        any gross malalignment should be corrected. Then the leg should be
        placed in a compression dressing with splints and elevated until the
        swelling has receded sufficiently for a safe open reduction. In order
        to avoid wound healing complications, patients should be seen and
        surgically treated as soon after the injury as possible (7). The operative complication rates are four times higher for diabetic (20,21) and obese patients managed operatively (22).
  • Complications
    • Incomplete reduction
      is associated with a higher incidence of ankle joint symptoms than are
      seen when anatomic restitution is achieved. This situation can be
      improved by osteotomy and internal fixation even years after the
      fracture occurs (23). The results after restoring the original anatomy overall are worse than those with early anatomic reduction (12).
    • Nonunion,
      although rare, can occur and is usually symptomatic. On the medial
      side, it may be associated with interposition of the posterior tibial
      tendon. Nonunion of either malleolus should be managed with internal
      fixation and bone grafting. Deep infection as the cause for the
      non-union has to always be ruled out with intraoperative cultures,
      especially after prior open reduction and internal fixation.
III. Pilon Fractures
Fractures of the articular surface of the tibia are
generally high-energy injuries from axial loads. They occur as a result
of high speed motor vehicle accidents or falls from a height (24).
  • Diagnosis is
    confirmed by radiographs, as for ankle fractures. The history of
    high-energy trauma or fall from a significant height should prompt a
    thorough examination of the heel, foot, and ankle paying special
    attention to swelling and tenderness. If the plain radiographs do not
    sufficiently document the fracture pattern, a computed tomographic (CT)
    scan is indicated to better delineate the size and location of the bony
  • Treatment.
    Fractures of the joint surface with more than 2 to 3 mm of
    displacement, either gapping or impaction, are generally managed by
    reduction, fixation, and in some occasions with bone grafting.
    Significant swelling of the soft tissues occurs very rapidly with this
    type of injuries; therefore, operative management must be emergent or
    otherwise delayed for several days or weeks until the swelling
    subsides. Plating of an associated fibula fracture, application of an
    external fixator across the ankle joint, or a calcaneal pin traction on
    a Bohler frame are valid options in the interim to achieve indirect
    reduction of the joint fragments and expedite the resolution of the
    soft tissue swelling. All those options limit the amount of soft tissue
    stripping required in subsequent surgeries which will help to achieve
    bony consolidation and to decrease the potential complications. Acute
    compartment syndromes are not uncommon with this type of fracture. If
    open fasciotomy is performed, then the fibula should be plated to
    restore some stability to the fracture. Because of the high incidence
    of wound complications and deep infections,


    is a trend toward limited fracture exposure, indirect reduction and
    fixation of the joint surface with lag screws, and complete definitive
    treatment with an external fixator or percutaneous plates. Bone
    grafting may not be required if the fracture is not exposed, but it
    should be carried out if there is any doubt.

  • Complications. Deep infection may require multiple debridements, hardware removal, and muscle-flap (often free) coverage (24).
    If the problem is identified early, then the hardware can be generally
    left in place. Pilon fractures are associated with a very high rate of
    complications, and their management should be left to a specialist
    familiar with this type of injury. Frequently, the long-term result is
    a stiff, painful, and chronically swollen ankle that at some point may
    require an ankle arthrodesis to improve the function and symptoms of
    the patient.
IV. Achilles Tendon (Tendo Calcaneus) Ruptures
  • The history
    associated with an Achilles tendon rupture is often diagnostic. The
    patient profile is a middle-aged individual occasionally involved in
    recreational sports, also known as “the weekend warrior.” Patients with
    a different profile are worth evaluating for risk factors (i.e.,
    steroid use) because this pathology is fairly unusual in a young
    healthy individual. It cannot be emphasized enough that a healthy
    tendon will not rupture during exercise. However, unhealthy tendons do
    not necessarily cause symptoms. Usually, the patient was running or
    jumping when a sudden severe pain was felt behind the ankle, almost as
    if it had been struck by something. Patients will describe the episode
    as being “…kicked by somebody, I turned around, and there was nobody
    there…” or being hit by a rock or the opponent’s racquet. Afterwards,
    the patient may be able to walk but usually with a significant
  • Examination
    is most easily accomplished with the patient prone. By inspection and
    palpation, the defect in the Achilles tendon can be documented.
    Squeezing the calf in this position with an intact Achilles tendon
    causes passive plantar flexion to occur; this response is absent with
    tendon rupture (Thompson’s test). Even if the plantar flexion is
    present but decreased, the diagnosis of Achilles tendon rupture can be
    made. Do not be misled by the patient’s ability to plantar-flex the
    ankle actively because this can be done with the muscles from the deep
    posterior compartment of the lower leg. Neurovascular exam is normally
    intact. In case of doubt, depending on the expertise of the radiology
    department, an ultrasound will be definitive to demonstrate a gap
    within the tendon fibers. If ultrasound is not available, an MRI will
    be diagnostic. The treatment guidelines are the same for either a
    partial or a complete rupture and are more dependent on the patient’s
  • Treatment
    • Patients with low functional demands may undergo nonoperative treatment.
      The foot is held in equinus for 8 weeks in a short-leg cast. It is
      extremely important not to force the plantar flexion excessively as the
      posterior aspect of the most distal part of the lower leg may develop
      skin necrosis from lack of blood supply. This can be easily
      demonstrated by the blanching of the skin that takes place with forced
      plantar flexion. The acute swelling also decreases the tolerance of the
      skin to plantar flexion. The position chosen for immobilization cannot
      compromise the posterior skin, and normal color has to be seen along
      the posterior aspect of the leg. Ambulation with crutches using an
      elevated heel on the shoe for 8 to 12 weeks then follows. Finally,
      rehabilitation exercises are begun to increase strength and range of
    • Operative treatment
      is often recommended, especially for the young, competitive athlete.
      The advantages of open treatment are that the proper strength-length
      relationship of the musculotendinous unit is re-established, the
      internal repair probably adds extra strength to the ruptured tendon,
      and immobilization can be limited. The risk of re-rupture of the tendon
      is lower with operative management (25). The
      incision should be made to one side of the tendon (not directly
      posteriorly) and should not extend distally into the flexor creases
      posterior to the ankle; this helps minimize adhesions of the tendon to
      the skin. A careful repair of the tendon sheath also limits these
      adhesions. The actual type of tendon repair is left to the discretion
      of the surgeon; numerous


      and patterns of suture repair have been discussed. The plantaris tendon
      or the flexor hallucis longus tendon transfer may be used to augment
      the repair. Postoperatively, the ankle is kept in a slight equinus
      position with a short-leg cast or boot for 8 weeks. Ambulation and
      physical therapy are then allowed as tolerated to increase strength and
      range of motion.

  • Complications.
    The rate of complications with either treatment, conservative or
    surgical, is similar. The difference is the type of complications which
    occur. With conservative treatment, the most common complications
    include re-rupture and weakness of the Achilles complex with plantar
    flexion. The weakness is more noticeable during the practice of sports
    and very rarely during activities of daily living (ADLs). With surgical
    treatment, the complications are related to skin dehiscence/necrosis,
    neurologic damage, and infection. There is no good data to recommend
    either treatment based on the type of complications. The final decision
    must be left to the patient once all the information is presented to
    him or her in an objective manner.
1. Lewis JE, Marymont JV. Ankle arthroscopy and sports-related injuries. In: Mizel MS, Miller RA, Scioli MW, eds. Orthopaedic knowledge update, foot and ankle 2. Rosemont, IL: American Orthopaedic Foot and Ankle Society, 1998:39–54.
2. Pneumaticos
SG, Noble PC, Chatziioannou SN, et al. The effects of rotation on
radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int 2002;23:107–111.
3. Dalton GP. Fractures of the talus. In: Mizel MS, Miller RA, Scioli MW, eds. Orthopaedic knowledge update, foot and ankle 2. Rosemont, IL: American Orthopaedic Foot and Ankle Society, 1998:39–54.
4. Bachmann
LM, Kolb E, Koller MT, et al. Accuracy of Ottawa ankle rules to exclude
fractures of the ankle and mid-foot: systematic review. BMJ 2003;326(7386):417.
5. Nabil
A, Ebraheim NA, Mekhail AO, et al. External rotation—lateral view of
the ankle in the assessment of the posterior malleolus. Foot Ankle Int 1999;20:379–383.
6. Bauer M, Bergstrom B, Hemborg A, et al. Malleolar fractures: non-operative versus operative treatment: a controlled study. Ankle Fractures 1985;199:17–27.
7. Carragee
EJ, Csongradi TZ, Bleck EE. Early complications in the operative
treatment of ankle fractures: influence of delay before operation. J Bone Joint Surg (Br) 1991;73:79–82.
8. Phillips WA, Schwartz HS, Keller CS, et al. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg (Am) 1985;67:67–78.
9. Franklin JL, Johnson KD, Hansen ST. Immediate internal fixation of open ankle fractures. J Bone Joint Surg (Am) 1984;66:1349–1356.
10. Belcher GL, Radomisli TE, Abate JA, et al. Functional outcome analysis of operatively treated malleolar fractures. J Orthop Trauma 1997;11:106–109.
11. Ponzer
S, Nasell H, Bergman B, et al. Functional outcome and quality of life
in patients with type B ankle fractures: a two year follow-up study. J Orthop Trauma 1999;13:363–368.
12. Donatto KC. Fractures of the ankle. In: Mizel MS, Miller RA, Scioli MW, eds. Orthopaedic knowledge update, foot and ankle 2. Rosemont, IL: American Orthopaedic Foot and Ankle Society, 1998:39–54.
13. Paiement
GD, Renaud E, Dagenais G, et al. Double-blind randomized prospective
study of efficacy of antibiotic prophylaxis for open reduction and
internal fixation of closed ankle fractures. J Orthop Trauma 1994;8:64–66.
14. Winkler
B, Weber BG, Simpson LA. The dorsal antiglide plate in the treatment of
Danis-Weber type-B fractures of the distal fibula. Clin Orthop Rel Res 1990;259:204–209.
15. Bostman
OM. Osteoarthritis of the ankle after foreign-body reaction to
absorbable pins and screws: a three to nine year follow-up study. J Bone Joint Surg (Br) 1998;80:333–338.


16. Dijkema
ARA, van der Elst M, Breederveld RS, et al. Surgical treatment of
fracture-dislocations of the ankle joint with biodegradable implants: a
prospective randomized study. J Trauma 1993;34:82–84.
17. Stromsoe K, Hoqevold HE, Skjeldal S, et al. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg (Br) 1995;77:920–921.
18. Hedstrom M, Ahl T, Dalen N. Early postoperative ankle exercise. Clin Orthop Rel Res 1994;300:193–196.
19. Sondenaa K, Hoigaard U, Smith D, et al. Immobilization of operated ankle fractures. Acta Orthop Scand 1986;57:59–61.
20. Flynn JM, Rodriguez-del Rio F, Pizá PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000;21:311–319.
21. McCormack RG, Leith JM. Ankle fractures in diabetics: complications of surgical management. J Bone Joint Surg (Br) 1998;80:689–692.
22. Bostman OM. Body-weight related to loss of reduction of fractures of the distal tibia and ankle. J Bone Joint Surg (Br) 1995;77:101–103.
23. Marti RK, Raaymakers EL, Nolte PA. Malunited ankle fractures. The late results of reconstruction. J Bone Joint Surg (Br) 1990;72:709–713.
24. Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg (Am) 1986;68:543–551.
25. Bomler J, Sturup J. Achilles tendon rupture. An 8-year follow-up. Acta Orthop Belg 1989;55:307–310.
Selected Historical Readings
Black HM, Brand RL, Eichelberger MR. An improved technique for the evaluation of ligamentous injury in severe ankle sprains. Am J Sports Med 1978;6:276–282.
Brantigan JW, Pedegana LR, Lippert FG. Instability of the subtalar joints. J Bone Joint Surg (Am) 1977;59:321–324.
Goergen TG, Danzig LA, Resnick D, et al. Roentgenographic evaluation of the tibiotalar joint. J Bone Joint Surg (Am) 1977;59:874–877.
Jacobs D, Martens M, van Audekercke R, et al. Comparison of conservative and operative treatment of Achilles tendon rupture. Am J Sports Med 1978;6:107–111.
Mast JW, Spiegel PG, Pappas JN. Fractures of the tibial pilon. Clin Orthop 1988;230:68–82.
Nistor L. Surgical and non-surgical repair of Achilles tendon rupture. J Bone Joint Surg (Am) 1981;63:394–399.
Ramsey P, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg (Am) 1976;58:356–357.
Yablon IG, Keller FG, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg (Am) 1977;59:169–173.

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