Ankle fracture: Difference between revisions

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==Approach==
{{Adult top}} [[ankle fracture (peds)]]
*Examine Joints above and below the ankle
==Background==
*Evaluate integrity of Achilles tendon (Thompson test)
[[File:Weber Classification - latin.png|thumb|Danis–Weber classification of ankle fractures (Types A, B and C).]]
*Always palpate proximal leg to rule-out [[Maisonneuve Fracture]] or fibulotibialis ligament tear
 
==Clinical Features==
*Examine for ecchymoses, abrasions, or swelling
*Vascular and neurologic assessment
**DP and PT pulses
**4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
*Note skin integrity and areas of tenderness or crepitus over ankle
*Range joint passively and actively to evaluate for stability
*Examine joints above and below the ankle
*Perform anterior drawer test (positive exam suggests torn ATFL)
*'''Always palpate entire length of fibula to rule-out [[Maisonneuve Fracture]] (fibulotibialis ligament tear)'''
**Perform a crossed-leg test to detect syndesmotic injury
**Perform a crossed-leg test to detect syndesmotic injury
*Evaluate integrity of Achilles tendon ([[Achilles Tendon Rupture#Clinical Features|Thompson test]])
*Palpate midfoot and base of 5th metatarsal for tenderness
==Differential Diagnosis==
{{Other ankle injuries DDX}}
{{Distal leg fractures DDX}}
{{Foot and toe fractures DDX}}
==Evaluation==
[[File:Danis–Weber classification on X-ray.jpg|thumb|Danis–Weber classification on X-ray.]]
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
[[File:WeberBAPMedp.jpg|thumb|Weber B AP]]
[[File:WeberCOBMedp.jpg|thumb|Weber C Oblique]]
[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]


==Imaging==
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture)
*[[Ottawa Ankle Rules]]
*3 views:
*3 views:
**AP
**AP: Best for isolated lateral and medial malleolar fractures
***Best for isolated lateral and medial malleolar fractures
**Oblique (mortise)
**Oblique (mortise)
***Best for evaluating for unstable fracture or soft tissue injury
***Best for evaluating for unstable fracture or soft tissue injury
***At a point 1cm proximal to tibial plafond space between tib/fib should be ≤6cm
***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
**Lateral  
**Lateral: Best for posterior malleolar fractures
***Best for posterior malleolar fractures
*Consider proximal tib/fib films and talus fractures
 
===Classification (Danis-Weber System)===
[[File:WeberclassRadioped.jpg|thumb|]]
*System based on level of the fibular fracture and characterizes stability of fracture
*Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)


==Classification (Danis-Weber System)==
====Type A====
System based on level of the fibular fx
*Fibula fracture below ankle joint/distal to plafond
**Medial malleolus often fractured
**Tibiofibular syndesmosis intact
**Usually stable: occasionally requires ORIF


===Type A (supination-adduction injury)===
====Type B====
*Fibula fracture at the level of the ankle joint/at the plafond
**Can extend superiorly and laterally up fibula
**Tibiofibular syndesmosis intact or only partially torn
**No widening of the distal tibiofibular articulation
**Medial malleolus may be fracture
**Possible instability
***Use gravity or weight bearing stress X-rays to determine stability <ref>Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1</ref>


*Fibular Fx at or below level of ankle joint (talar mortise) without syndesmotic involvement
====Type C====
*Typically stable
*Fibula fracture above the level of the ankle joint/proximal to plafond
*Deltoid ligament usually intact, medial malleolus usually fx
**Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
**A1: isolated
**Medial malleolus fracture
**A2: medial malleolus fx
**Unstable: requires ORIF
**A3: posteromedial fx


===Type B (supination-external rotation injury)===
==Management & Disposition==
*Fibular Fx at level of ankle joint (talar mortise) w/ partial syndesmotic ligament injury
{{General Fracture Management}}
*Stability dictated by integrity of tibiofibular syndesmosis (no widening of distal tibiofibular articulation)
*Deltoid ligament may be torn, medial malleolus usually fx
**B1: isolated
**B2: medial lesion (either malleolus or ligament)
**B3: medial lesion and fx of posterolateral tibia


===Type C (pronation-eversion injury)===
===General Ankle Fracture===
*Fibular Fx above level of ankle joint (talar mortise) w/ complete syndesmotic disruption
*Determined by stability of fracture:
*Unstable (widened distal tibiofibular articulation) and require surgical correction
**Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
*Deltoid ligament torn, medial malleolus fx
**Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint
**C1: simple diaphyseal fibular fracture
**C2: complex diaphyseal fibular fracture
**C3: proximal fracture


[[File:WeberclassRadioped.jpg|center|frame|300px]]<br>
===Isolated lateral malleolar fracture===
*If stable (see Weber classification) treat like severe [[Ankle Sprain]]  
*Signs of instability:
**Displacement >3mm
**Associated medial malleolus fracture
**Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
**Widening of medial clear space (suggests deltoid ligament injury)


==Management==
===Isolated medial or posterior malleolar fracture===
# Lateral malleolar Fx (isolated)
*Must rule-out other injuries  
## Treat like severe ankle sprain unless unstable:
*If non-displaced, isolated:  
###Displacement >2mm
**[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)  
###Medial fx
**Non-weight bearing  
##Widening of medial clear space (deltoid injury)
**Refer to Ortho in 5-7d  
#  Medial or posterior malleolar Fx
## Must rule-out other injuries
## If non-displaced, isolated:
### [[Short-Leg Posterior Splint]] (ankle at 90')
### Non-weight bearing
### Refer in 5-7d
#Lateral malleolar fx with deltoid injury OR bimalleolar OR trimalleolar fx
##[[Short-Leg Posterior Splint]] (ankle at 90o)
##Immediate consultation in ED


==X-rays==
===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture===
[[File:WeberARadiopediaOB.jpg|center|frame|100px|Weber A Oblique]]
[[File:Bimalleolar fracture legend.jpg|thumb|Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.]]
[[File:WeberBRadiopedOB.jpg|center|frame|50px|Weber B Oblique]]
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)
[[File:WeberBAPMedp.jpg|center|frame|50px|Weber B AP]]
*Immediate reduction or ortho consult in ED
[[File:WeberCOBMedp.jpg|center|frame|100px|Weber C Oblique]]
[[File:WeberCAPMedp.jpg|center|frame|100px|Weber C AP]]


==See Also==
==See Also==
*[[Ankle (Main)]]
*[[Ankle Sprain]]
*[[Ankle Sprain]]
*[[Ankle Fracture (Peds)]]
*[[Ankle Fracture (Peds)]]
*[[Ottowa Ankle Rules]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve Fracture]]
*[[Maisonneuve Fracture]]
*[[Pilon Fracture]]
*[[Pilon Fracture]]
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*[[Splinting]]
*[[Splinting]]


==Source==
==External Links==
*Tintinalli, Radiopaedia.org (Images by Dr. Frank Gaillard), Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)
*http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
*Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378


[[Category:Ortho]]
==References==
<references/>
[[Category:Orthopedics]]

Latest revision as of 22:50, 5 March 2025

This page is for adult patients. For pediatric patients, see: ankle fracture (peds)

Background

Danis–Weber classification of ankle fractures (Types A, B and C).

Clinical Features

  • Examine for ecchymoses, abrasions, or swelling
  • Vascular and neurologic assessment
    • DP and PT pulses
    • 4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
  • Note skin integrity and areas of tenderness or crepitus over ankle
  • Range joint passively and actively to evaluate for stability
  • Examine joints above and below the ankle
  • Perform anterior drawer test (positive exam suggests torn ATFL)
  • Always palpate entire length of fibula to rule-out Maisonneuve Fracture (fibulotibialis ligament tear)
    • Perform a crossed-leg test to detect syndesmotic injury
  • Evaluate integrity of Achilles tendon (Thompson test)
  • Palpate midfoot and base of 5th metatarsal for tenderness

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

Danis–Weber classification on X-ray.
Weber A Oblique
Weber B Oblique
Weber B AP
Weber C Oblique
Weber C AP
  • Ottawa Ankle Rules (sen 96-99% for excluding fracture)
  • 3 views:
    • AP: Best for isolated lateral and medial malleolar fractures
    • Oblique (mortise)
      • Best for evaluating for unstable fracture or soft tissue injury
      • At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
    • Lateral: Best for posterior malleolar fractures
  • Consider proximal tib/fib films and talus fractures

Classification (Danis-Weber System)

WeberclassRadioped.jpg
  • System based on level of the fibular fracture and characterizes stability of fracture
  • Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)

Type A

  • Fibula fracture below ankle joint/distal to plafond
    • Medial malleolus often fractured
    • Tibiofibular syndesmosis intact
    • Usually stable: occasionally requires ORIF

Type B

  • Fibula fracture at the level of the ankle joint/at the plafond
    • Can extend superiorly and laterally up fibula
    • Tibiofibular syndesmosis intact or only partially torn
    • No widening of the distal tibiofibular articulation
    • Medial malleolus may be fracture
    • Possible instability
      • Use gravity or weight bearing stress X-rays to determine stability [1]

Type C

  • Fibula fracture above the level of the ankle joint/proximal to plafond
    • Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
    • Medial malleolus fracture
    • Unstable: requires ORIF

Management & Disposition

General Fracture Management

General Ankle Fracture

  • Determined by stability of fracture:
    • Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
    • Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint

Isolated lateral malleolar fracture

  • If stable (see Weber classification) treat like severe Ankle Sprain
  • Signs of instability:
    • Displacement >3mm
    • Associated medial malleolus fracture
    • Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
    • Widening of medial clear space (suggests deltoid ligament injury)

Isolated medial or posterior malleolar fracture

  • Must rule-out other injuries
  • If non-displaced, isolated:

Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture

Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.

See Also

External Links

References

  1. ↑ Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1
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