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1. Ankle and Foot Fractures
Description
A fracture is an interruption of the continuity of bone, this page will discuss
ankle and foot fractures and the role that physiotherapists play in the
rehabiliation of such injuries. Fractures of the ankle joint are common
amongst adults. Kannus et al. report an incidence of up to 174 cases per 100
000 persons per year in a Finish population.[1] Fractures of the foot are less
common.
Fractures of the ankle
Ankle fractures are most commonly diagnosised through clinical examination
and x-ray. Ottawa rules provide clinicians with a tool to decide whether the
joint should be imaged or not. Several classifications exist and are used to
determine severity of injury and management. Examples are Dannis-Webber
that identifies level of injury and Lauge-Hansen and uses mechanism of the
injury.
Complications include reduced range of motion at the ankle and foot joint as a
result of peri-articular and intra-articular adhesions or disruption of articular
surfaces. Disruption to articular surfaces may lead to development of
osteoarthritis.
Fractures without displacement can be treated with a below knee cast that may
be applied for 3-6 weeks. If displaced, a surgeon should reduce the fragments
to there normal anatomical position of the joint. If this cannot be achieved by
manipulation and plaster cast then an individual may have to undergo an open
reduction with internal fixation (ORIF) followed by immobilisation in a plaster
cast.[2]
 Potts Fracture
 Avulsion Fractures

2. Fractures in the foot
The bony anatomy of the foot means that there are a variety of fractures.
Fractures of the calcaneum often occur as a result of a fall from height. Such
fractures can be very painful and may be accompanied by vertebral fractures.
The phalanges and metatarsals are commonly injuried by a heavy object falling
onto the foot. These fractures do not require reduction or immobilisation.
Stress fractures of the metatarsals are known as a 'March' fracture. These are
caused by repeated trauma from pronlonged walking.[2]
 Calcaneal Fractures
 Chopart fracture-dislocation
 Metatarsal Fractures
Stress Fractures
Stress fractures occur in bones that undergo mechanical fatigue.[3] They are a
consequence of exceeding repetitive submaximal loads, which creates an
imbalance between bone resorption and bone formation.[4] The fractures
usually begin in locations of great stress; this is called “crack initiation”.[4] If
this microscopic crack is not able to heal and is subjected to further loading,
the microdamage will increase and the crack will enlarge. This increase in
damage can cause the bone to break on a macroscopic level.[4]
 Leg and Fott Stres Fractures
Clinically Relevant Anatomy
The ankle joint
The ankle joint also known as talocrural joint is made up of three bony
structures: the distal ends of the tibia (shinbone) and fibula and the talus. The
tibia and fibula have specific parts that make up the ankle:
 Medial malleolus - inside part of the tibia
 Posterior malleolus - back part of the tibia
 Lateral malleolus – end of the fibula

3. The tibia and fibula form the ankle joint with structure and stability provided
by connective tissues:
 Interosseous membrane
 Anterior, posterior, and transverse tibiofibular ligaments
The collateral ligaments stabilize the joint against abduction and adduction
forces. Laterally, the anterior talofibular ligament (ATFL), calcaneofibular
ligament (CFL), and posterior talofibular ligament (PTFL), and, medially, the
broad fan of the deltoid ligament and the plantar calcaneonavicular ligament,
whose medial border is blended with the forepart of the deltoid ligament.[5]
The foot
The foot contains 26 bones. The foot is divided into three main parts:
hindfoot, midfoot and forefoot.
 Hindfoot is composed of 2 bones, calcaneus and talus. They form the subtalar
joint
 Midfoot is made up of 5 bones, navicular, cuboid and 3 cuneiforms (medial,
intermediate and lateral). The bones are connected to the forefoot and the
hindfoot by muscles and the plantar fascia (arch ligament).
 Forefoot is consists of 19 bones, which are 5 metatarsals, 14 phalanges.
The Chopart joint is the connection between the hindfoot to the midfoot
involving the ‘talonavicular joint’ and the ‘calcaneocuboid joint’; the Lisfranc
joint connects the forefoot to the midfoot.
Epidemiology /Etiology
Ankle fracture is caused by traumas such as falls, twisting injuries and sports-
related injuries[6][6], and therefore it does not only occur in the older, but also in
the young and active population.
There are a number of risk factors associated with an increased risk of
sustaining foot and ankle fractures including smoking, diabetes, obesity,
previous falls and/or fractures, very high or low levels of physical activity, and
low bone mineral density (BMD). For older individuals over an age of 50,
additional risk factors include female gender, comorbidities and multiple
medications.

4. The higher level of activity in younger males, particularly in risk taking and
sports activities, might explain the high rates of ankle and foot fractures in this
age group. Younger female, under the age of 50, less active than males,
however they have a higher tendency to fall, later in life which coincides with
postmenopausal bone loss, resulting in an increase in fracture risk.[7]
Characteristics/Clinical Presentation
 Difficulties or even inability to walk or load the ankle. (it is possible to walk
with less severe breaks, so never rely on walking as a test of whether a bone has
been fractured.
 Pain
 Swelling
 Bruising (soon after the injury).
 Difference in appearance.
 Observable differences compared to the unaffected side
When an ankle has been broken, there is not only structural damage to the
skeletal structure, but also to the ligament tissue (deltoid ligament and the
anterior and posterior tibiofibular ligaments) and possibly nervous and
musculoskeletal tissue around the ankle complex. This can result in impaired
balance capacity, reduced joint position sense, slowed nerve conduction,
velocity, impaired cutaneous sensation and decreased dorsal extension range
of motion[6]
Fracture Classifications
Ankle fractures can be classified according to either the AO/OTA, Danis-
Weber or Lauge-Hansen classification system.
The Lauge-Hansen classification is based on a rotational mechanism of injury.
There are 4 categories and 13 subgroups of ankle fractures detailed in the table
below.
Categories Stage (subgroups)
Supination external rotation (SER) 1. Injury of the anterior inferior tibiofibular ligament
2. Oblique/spiral fracture of the distal fibula
3. Injury of the posterior inferior tibiofibular ligament or avulsion o
4. Medial malleolus fracture or injury to the deltoid ligament
Supination adduction (SA) 1. Transverse fracture of the distal fibula
2. Vertical fracture of the medial malleolus
Pronation external rotation (PER) 1. Medial malleolus fracture or injury to the deltoid ligament
2. Injury of the anterior inferior tibiofibular ligament

5. 3. Oblique/spiral fracture of the fibula proximal to the tibial plafond
4. Injury of the posterior inferior tibiofibular ligament or avulsion o
Pronation abduction (PA) 1. Medial malleolus fracture or injury to the deltoid ligament
2. Injury of the anterior inferior tibiofibular ligament
3. Transverse or comminuted fracture of the fibula proximal to the t
The Danis-Weber classification is based on radiographic criteria. It took into
consideration the position of the distal fibular fracture in relation to the
syndesmosis of the ankle joint. Three categories were created:
 Type A fracture: below the level of the tibial plafond (syndesmosis) and may be
associated with oblique or vertical medial malleolar fractures
 Type B fractures: at the level of the tibial plafond (syndesmosis) and extend
proximally in an oblique fashion
 Type C fractures: proximal to the level of the tibial plafond and often have an
associated syndesmotic injury. It can be associated with medial malleolus
fractures or injury to the deltoid ligament.[5][8]
The AO and Lauge-Hansen classification systems are widely used in the
clinical diagnosis of ankle injuries. The AO classification system is simple to
understand, and it emphasizes the coordinating role of the fibula and
syndesmosis of the ankle joint. The Lauge-Hansen classification system
emphasizes the different stages of pathological damage in addition to the
fracture pattern, and it insists on the understanding of damage to the ankle
ligament system. It can provide an extensive assessment of ankle injuries.
Compared to Lauge-Hansen classification, AO classification system is more
reliable and reproducible and thus has more value in clinical practice, than the
Lauge-Hansen classification system. Despite this, the Lauge-Hansen
classification system stands as the basis for understanding the mechanics of
ankle fractures.[9]
AO classification/OTA system classifies all long bone fractures with a
systematic approach, based on location, topography, and extent of bony lesion.
It is based on radiographic criteria and incorporates the mechanism of injury.
The fractures are classified as infrasyndesmotic, transsyndesmotic and
suprasyndesmotic with further subcategories based on the presence or absence
of medial or posterior malleolar injuries.
The table below compares the Danis-Weber, Lauge-Hansen, and AO/OTA
classification systems.
Fibular fracture location Danis-Weber classification Lauge-Hansen classification
SAD I, II
AO/OTA classific
Infrasyndesmotic Type A SAD I, II 44-A1 (isolated la

6. 44-A2 (lateral and
44-A3 (lateral, me
Transsyndesmotic Type B SER I, II, III, IV 44-B1 (isolated lat
44-B2 (lateral and
44-B3 (lateral, me
Suprasyndesmotic Type C PER I, II, III, IV
PA I, II, III
44-C1 (simple dia
44-C2 (multifragm
44-C3 (proximal
OTA = Orthopaedic Trauma Association; SAD = supination adduction; SER =
supination external rotation; PER = pronation external rotation; PA =
pronation abduction.[8]
Differential Diagnosis
 Rheumatoid Arthritis
 Gout and Pseudogout
 Ankle Dislocation
 Ankle Impingement
 Compartment Syndrome of the Foot
 Deep Venous Thrombosis
 Peroneal Tendinopathy
 Sinus Tarsi Syndrome
 Ankle ligament sprains.
The clinical presentation of some subtle fractures of the ankle can be similar to
that of ankle sprains. This similarity makes that ankle fracture is often
mistaken as ankle sprain. These injuries are quite different and need an
accurate and early diagnosis.[10]
Diagnostic Procedures
Ottawa rules
Ankle X-ray is only required if there is any pain in the malleolar zone and any
one of the following:
 Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of
the medial malleolus, OR
 Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip
of the lateral malleolus, OR
 An inability to bear weight both immediately and in the emergency department
for four steps.

7. Additionally, the Ottawa ankle rules indicate whether a foot X-ray series is
required. It states that it is indicated if there is any pain in the midfoot zone
and any one of the following:
 Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
 Bone tenderness at the navicular bone (for foot injuries), OR
 An inability to bear weight both immediately and in the emergency department
for four steps.
Ankle fractures are initially evaluated by physical examination and then by x-
ray.[5]
To reduce the use of x-rays, an intrasound device can be used to detect
malleolar fractures even though it cannot be relied upon alone due to an 85%
sensitivity and 52% sensitivity.[11]
Ultrasound had good sensitivity and specificity for diagnosing fifth metatarsal,
lateral and medial malleolus fractures in patients with foot and/or ankle
sprains. However, sensitivity and specificity of ultrasound for navicular
fractures were low.[8]
Imaging

Outcomes Measures
 SF-36 includes 8 categories: Physical functioning, Physical role, Bodily pain,
General health, Vitality, Social functioning, Emotional role and Mental
health)[12]
 Kerr-Atkins score for pain and function after calcaneal fracture leading to a best
score of 100points.[6]
 EuroQol (EQ-5D) to measure the Quality of life and general health status[6]
 American Orthopaedic Foot and Ankle Society score based on 9 items: pain,
activity and functional limitations, walking distance, difficulties with different
terrains, gait abnormality, sagittal range of motion at the ankle and range of
motion at the subtalar joint, stability, and alignment[13]
 Olerud-Molander Ankle Score (OMAS), is an ordinal rating scale from 0 points
(totally impaired function) to 100 points (completely unimpaired function)
related to 9 different items given different points: pain, stiffness, swelling, stair
climbing, running, jumping, squatting, supports and work/activity level.[14]
 FAOS is also a self-administered patient questionnaire and consists of 42 items
divided into five subscales: pain, other symptoms, function in daily living
(ADL), function in sport + recreation + foot and ankle-related quality of life.[14]
 Global self-rated ankle (GSRF) to evaluate their present ankle function[14]
 The American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS)
score contains 3 components: pain (40 points), function and alignment on a
scale of 0- 100 points, 100 best possible score[7]

8.  Foot Function Index (FFI) consists of 23 questions to measure the impact of
foot pathology on function in terms of pain, disability and restriction of activity.
The lower the score, the better outcome[7]
Medical Management
Most patients with a malleolus fracture require 6 weeks of immobilisation.
Patients with an initially non-displaced fracture or who were treated surgically
will generally require 4 weeks of non-weight bearing in a short-leg cast or
removable walking boot, followed by 2 weeks in a walking cast or boot. The
removable boot will allow for earlier range-of-motion exercises.
Surgery is needed for many types of ankle fractures. While not always
necessary, surgery for ankle fractures is not uncommon. The need for surgery
depends on the appearance of the ankle joint on X-ray and the type of ankle
fracture.
The goals of surgery are always the smooth anatomical reconstruction of the
joint surface and the protection of the injured ligamentous structures to
enable early postoperative functional therapy of the joint. Adequate reduction
with congruency of the joint has been reported as one of the most important
indications of a good end result. Inadequate reduction may lead to
osteoarthritis.
The timing of definitive surgical treatment depends mainly on the soft-tissue
findings, is possible only if the soft tissues are not critically vulnerable (few
hours after the trauma). And so the need for surgery depends on the
appearance of the ankle joint on X-ray and the type of ankle fracture.
While not always necessary, surgery for ankle fractures can be done with 3
kinds of metal plate and multiple screws: one-third tubular plate; locking
compression (LCP) metaphyseal plate for lateral malleolar fracture and Weber
B fracture; LCP distal fibula plate Weber A fracture and Weber B fracture.[5][15]
Types of plates- from left to right: conventional one-third tubular plate; a LCP metaphyseal plate; a
LCP distal fibula plate
Physical Therapy Management

9. Fractures that are stable with non-displaced or only slightly displaced
fragments can be treated conservatively. Type A fractures do not need to be
immobilised in a cast, but can rather be treated like external ligament ruptures
in a stabilising ankle orthosis for early function with pain-adapted full weight-
bearing.[5]
Passive joint mobilization
More significant fractures are immobilised and require a rehabilitation
program after cast removal. Programs should be patient centred and take into
consideration patient goals and aspirations. Programs tend to include ankle
mobility, strengthening exercise, weight bearing and balancing exercise.
Physiotherapists should empower the patient with home exercises and provide
education and advice.[6]
Patients frequently complain of difficulties with activities involving the lower
limb, such as stair climbing, walking and reduced participation in work and
recreation. Impairments can be pain, swelling, stiffness, muscle atrophy and
decreased muscle torque[9], impaired ankle mobility, impaired balance capacity
and increased ankle circumference[6] at the ankle after cast removal.
Passive joint mobilisation can be used to work on the problems of pain and
joint stiffness, in order to allow an earlier return to activities. For this
technique, the physiotherapist manually glides the articular surfaces of a joint
to produce oscillatory movements.[16] Manual techniques should be
complimentary to a program that includes active exercise.
Strength-training may be beneficial after fracture and should be considered as
an important rehabilitation option by physiotherapy. Because strength loss is
one of the most common complications by a foot or ankle fracture.[17]

10. Home exercise program
Key Research
 Fractures of the Ankle Joint: Investigation and Treatment Options.[5]
 Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot:
systematic review.[18]
Resources
 Orthopaedic Surgery ucsf. Ankle Physical
Examination. http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-
medicine/physical-examination-info/ankle-physical-examination/ (accessed 24
Aug 2014).
References
1. Jump up↑ Kannus P, Palvanen M, Niemi S, Parkkari J, Jrvinen M. Increasing
number and incidence of low-trauma ankle fractures in elderly people: finnish
statistics during 1970–2000 and projections for the future. Bone.
2002;31(3):430-433.
2. ↑ Jump up to:2.0 2.1 Tidy N, Porter S. Tidy's physiotherapy. 13th ed. Edinburgh:
Elsevier; 2013.

11. 3. Jump up↑ Edwards WB, Taylor D, Rudolphi TJ, Gillette JC, Derrick TR. Effects
of running speed on a probabilistic stress fracture model. Clinical
Biomechanics. 2010;25:372-377.
4. ↑ Jump up to:4.0 4.1 4.2 Maffulli N, Longo UG, Denaro V. Femoral Neck Stress Fractures.
Operative Techniques in Sports Medicine. 2009;17:90-93.
5. ↑ Jump up to:5.0 5.1 5.2 5.3 5.4 5.5 Goost H et al. Fractures of the Ankle Joint: Investigation
and Treatment Options. Dtsch Arztebl Int. 2014; 111(21): 377–
388.fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075279/ (
6. ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 6.6 Peter J. Daly et al. Epidemiology of ankle fractures in
Rochester, Minnesota, Acta Orthopaedica Scandinavica. 1987; 58:5, 539-544
7. ↑ Jump up to:7.0 7.1 7.2 Holloway KL et al. Foot and Ankle Fracture Incidence in South-
Eastern Australia: An Epidemiological Study. Clin Res Foot Ankle 2014, 2:4
8. ↑ Jump up to:8.0 8.1 8.2 Jason P. Tartaglione et al. Classifications in Brief: Lauge-Hansen
Classification of Ankle Fractures. Clin Orthop Relat Res (2015) 473:3323–3328
9. ↑ Jump up to:9.0 9.1 Meng-chen Y et al. Evaluating the Reliability and Reproducibility of
the AO and Lauge-Hansen Classification Systems for Ankle Injuries.
Orthopedics. 2015; 38(7): 626-30.
10. Jump up↑ Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle
sprains. Am Fam Physician. 2002; 66(5):785-94.
11. Jump up↑ Dancocks A et al. A pilot study to assess the sensitivity and specificity
of an intrasound device in the diagnosis of ankle fractures. J Accid Emerg Med.
1997; 14(4): 230–232.
12. Jump up↑ Westphal T, Piatek S, Halm JP, Schubert S, Winckler S. Outcome of
surgically treated intraarticular calcaneus fractures - SF-36 compared with
AOFAS and MFS. Acta Orthopaedica Scandinavica. 2004; 75(6): 750-755.
13. Jump up↑ Van Schie-Van der Weert EM, Van Lieshout, EMM, De Vries MR, Van
der Elst M, Schepers T. Determinants of outcome in operatively and non-
operatively treated Weber-B ankle fractures. Arch Orthop Trauma Surg. 2012
Feb; 132(2): 257–263.
14. ↑ Jump up to:14.0 14.1 14.2 Nilsson GM, Eneroth M, Ekdahl CS. The Swedish version of
OMAS is a reliable and valid outcome measure for patients with ankle fractures.
BMC Musculoskelet Disord. 2013; 14: 109.
15. Jump up↑ Huang Z et al. Comparison of three plate system for lateral malleolar
fixation. BMC Musculoskelet Disord. 2014; 15: 360.
(2B).fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223732/
16. Jump up↑ Lin C CH, Moseley AM, Refshauge KM, Haas M, Herbert RD.
Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a
protocol for a randomised controlled trial. BMC Musculoskeletal Disorders
2006;7:46
17. Jump up↑ Murdoch A, Taylor N, Dodd K. Physical therapist should consider
including training as part of fracture rehabilitation. Physical Therapy Reviews
(2004) Mar(9) 1 51 – 59
18. Jump up↑ Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude
fractures of the ankle and mid-foot: systematic review. BMJ 2003; 236:417
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