External Ankle Fracture, Surgery and Recovery

Surgical intervention for an external ankle fracture


Fixation with side plate

This procedure makes sense if the bone quality is good. In a transverse fracture, the large lateral malleolus fragments can be fixed in the tibiofibular syndesmosis with a shaped plate and light compression.

Side wires

The Kirschner wires convert the lateral tensile forces into compressive forces.
With this method of fixation, the opposing bone cortex ( cortex ) must be able to withstand the compression.

The figure of eight coiled wires are located on the lateral surface of the lateral malleolus and act like a taut band when fixed.
The Kirschner wire must be of sufficient strength to withstand the tension created (diameter 0.8 mm).

Procedure for external ankle fracture

Isolated lateral malleolus fracture

First, an incision is made on the side of the outer malleolus, along the fibula line. The soft tissues are severed up to the injured area. The fracture is cleaned (e.g. removal of a blood clot) and the bone fragments are combined.

The surgeon must attempt to reposition the bones into their exact, anatomical position (restoration of the axis).
Once the fracture is established, the fibula fragments can be stabilized in a number of ways.
The most common method is to insert a lag screw into the fractured part of the bone.
A metal plate is then attached to the bone with a series of screws to stabilize the fibula.
The plate generally uses 5-6 screws and is placed above and below the fracture.

bimalleolar fracture

In this case, both the external and the internal ankle fracture must be treated surgically.
These two operations are performed separately, i.e. with two different incisions, but under the same anesthesia.
The aim of the procedure is to correct the fractures in order to return the ankle to its original position (before the accident) and give it the greatest possible stability.

Trimalleolar fracture

The procedure is similar to that of the bimalleolar fracture, but here a fragment of the rear edge of the tibia must also be treated.
If the bone fragment represents less than 20% of the articular surface of the tibia, this fracture can be neglected and the fracture treated as a bimalleolar fracture.
If the fragment exceeds 20%, reduction is necessary.

The placement of the piece of bone is done in a manner similar to that of a lateral malleolus fracture, or by making an incision at the posterior aspect of the ankle. Once the fracture has been properly reduced, it is usually secured with one or two screws at the front and back of the ankle.

Stabilization of a syndesmotic ligament injury

When the strong fibrous tissues (syndesmotic ligaments) that hold the tibia and fibula together are torn or completely torn, they need repair.
The surgeon will check syndesmosis stability before and during surgery; tension is placed on the ankle joint using a fluoroscope (portable X-ray based fluoroscopy device); this way, the doctor can see if the joint is performing an exaggerated movement (i.e., if the ankle bone comes out of its seat when pressed).

If the syndesmotic ligament is classified as unstable, it must be stabilized so that it can heal in the correct position (reposition).
The syndesmosis is usually stabilized by inserting a screw or two into the tibia or fibula to fix these bones and allow the syndesmosis to heal.
The screws are removed after approx. 3-6 months (when the syndesmosis ligament has strengthened again).
In some cases, the surgeon can repair the syndesmosis directly with the help of sutures.

Prognosis for lateral ankle fracture

Patients with lateral ankle fractures can fully restore their original state of health with appropriate (conservative or surgical) treatment.
The return to professional and sporting activities takes between 6 weeks and a few months and should only take place after the approval of the treating doctor.

For compound fractures or additional injuries to other bones, soft tissue, nerves, or blood vessels, recovery times are much longer.

Patients with smaller, undisplaced fractures (eg, avulsion fractures where the tendon tears off a small piece of bone) can resume physical activity in less than 6 weeks with the approval of their doctor and physiotherapist.

  • It can take up to a year for the bone to withstand a heavy load.
  • Once the healing process is complete, everyday activities can be fully resumed.
  • The patient must know not to overload the bone until it has fully healed.
  • Heavy work and strenuous sports may only be resumed with the consent of the attending physician.

External ankle fracture rehabilitation

  • Rehabilitation plays an important role regardless of the treatment method of the fracture.
  • The aim of postoperative rehabilitation is to relieve pain and regain the original mobility of the ankle.
  • Local cold treatment (ice) may be helpful to reduce pain and swelling.
  • Magnetic therapy is very effective in the treatment of fractures because it accelerates the formation of bone callus.
  • Patients should be encouraged to continue functional activities to prevent the complications arising from inactivity and bed rest.
  • The physiotherapist must explain to the patient the correct use of the crutches so that the process of walking can be resumed as quickly as possible.
  • The patient can switch from walkers to crutches and eventually to the cane once the broken leg is allowed to bear weight.

If the patient wears a cast, he must perform exercises to maintain nearby joint mobility and muscle tone of the affected limb if doing so does not compromise fracture stability.

Once the cast is removed, exercise therapy (physiokinesiotherapy) to regain range of motion, a proprioceptive exercise program to improve balance, and ankle strengthening exercises are important.

Passive mobilization requires the physiotherapist to focus on dorsiflexion (pulling the toe toward the body) because if the toe is not lifted, there is a risk of stumbling while walking.
The intensity and difficulty of the exercises should be increased slowly until the original functionality is restored.
Patients with accompanying pathologies (mostly older people) usually need physiotherapy tailored to their individual needs so that the ankle joint can regain its strength and mobility.

Swelling (edema) is a common problem that can be controlled with ice packs and pressure bandages or kinesio taping .

If the fracture was treated surgically, the rehabilitation protocol must be determined by the attending physician.

Complications of lateral ankle fracture

  • injury to soft tissue and skin,
  • False joint formation (pseudoarthrosis),
  • Axis misalignment and loss of surgical fixation,
  • infection ,
  • Arthritis,
  • pain on the means of synthesis (nails, plates, screws),
  • tiefe Venenthrombose,
  • muscle wasting (atrophy),
  • remaining functional limitation.

Complications are more frequent in diabetics with concomitant pathologies: a higher rate of mortality and of postoperative complications in the hospital, as well as a longer hospital stay.

The operational risks are:

  • residual pain,
  • displacement or breakage of the nail,
  • nail loosening,
  • instability of fixation,
  • False joint formation (pseudoarthrosis),
  • axis misalignment,
  • compartmentsyndrome,
  • tiefe Venenthrombose,
  • The risk of anesthesia,
  • heart attack , stroke and death.

Post-treatment (controls)

Post-OP: Elevation and medication.

  • 7th-10th Day 2: Control of the wound, use of an orthosis (aircast splint).
  • partial load, if possible.
  • Beginning a daily active and passive exercise program to move the ankle without   a brace .
  • 6 weeks: X-ray and assessment of the fracture.
  • Continuation of physical therapy .
  • After 8 weeks, driving a car is allowed again if the right leg was injured. Swelling often occurs
    after an ankle sprain and after fixation.
  • Wear compression stockings.
  • 3 months: Start of sport-specific rehabilitation.
  • Climbing stairs and sports are not allowed until the ankle has regained its full range of motion.
  • 6 months: Resume sports and daily activities as before the injury.
  • 1 year: X-ray and evaluation.