Types of Ankle Fractures & Injuries
This is my ankle— the first time out of a cast— two weeks post op after an ORIF surgery for a bimalleolar fracture and ruptured tendon.
You broke your ankle. Unfortunately, that’s the short version.
FROM THE TRENCHES
One of the first things you discover in an ankle-fracture community is just how many versions of a “broken ankle” there are.
You’ve got your single clean break, all the way through to fractures on both sides of the ankle, plus dislocations, tendon tears and a slew of other fun injuries, often piled on top of each other. (Don’t ask me how I know that last bit.)
And then comes the inevitable comparison:
You're walking already?
You're still non-weight-bearing?
You didn't need surgery?
You have how many screws?
Those comparisons can be useful. It can be reassuring to hear from people who have been through something similar, and they can give you an idea of what recovery may involve. But it can be scary, too, wondering if you’re going to be as bad off as the fracture friend who’s crying in a Facebook post.
Just remember the important word is similar.
Someone else's experience can help you know what questions to ask, but it can't give you your own recovery schedule. Use other people's recovery stories for information, encouragement and companionship — not as a stopwatch.
Understanding Your Ankle Injury
Ankle injuries come in an almost bewildering number of combinations. You can break one bone or several. A fracture can stay neatly aligned or shift out of position. Ligaments, tendons and other structures around the joint can be injured at the same time.
That helps explain one of the most confusing things about ankle-fracture recovery: Two people can both say, “I broke my ankle,” yet have completely different treatment, restrictions and recovery timelines.
This chapter isn't intended to cover every possible ankle fracture or injury. There are simply too many variations, and your imaging and medical team are the best sources for the specifics of your injury. Instead, consider this a guide to some of the terms you're likely to encounter — and to why the details of your particular injury matter.
First, a Little Ankle Anatomy
“The foot bone’s connected to the ankle bone…”
— “Dem Bones” (also known as “Dry Bones”), traditional spiritual
The ankle is a complex, weight-bearing joint. Three bony areas form the bumps around the ankle that doctors call the malleoli:
The lateral malleolus is the end of the fibula on the outside of the ankle.
The medial malleolus is part of the tibia on the inside of the ankle.
The posterior malleolus is at the back of the tibia.
A fracture may involve one or more of these areas. That's where terms such as unimalleolar, bimalleolar and trimalleolar fracture come from.
But bones are only part of the picture. Ligaments hold the ankle joint together, while tendons connect muscles to bone and help move and stabilize the ankle. Those structures can be injured along with a fracture — sometimes significantly.
Stable, Unstable and Stress Fractures
One of the most important distinctions isn't simply which bone broke, but whether the ankle remains stable.
With a stable fracture, the broken bone remains in acceptable alignment and the ankle joint remains stable. These fractures can often be treated without surgery, using a cast, boot or brace while the bone heals.
An unstable fracture involves loss of normal alignment or stability of the ankle joint. Surgery may be needed to restore and maintain the position of the bones and joint.
Stress fractures are different again. Instead of resulting from one dramatic accident, they are tiny cracks in bone associated with repetitive stress. Pain often develops gradually and worsens with activity.
This is one reason comparing treatment with somebody else's can be so misleading. A person with a stable fracture may be walking in a boot while another person with what sounds like a similar “broken ankle” may have undergone surgery and been told not to put weight on the leg.
The details matter.
One, Two or Three Malleoli
One little, two little, three little malleoli…
You may hear your fracture described according to how many malleoli are involved.
A fracture involving one malleolus is generally called unimalleolar. A bimalleolar fracture involves two, and a trimalleolar fracture involves the medial, lateral and posterior malleoli.
Generally, injuries involving more of the ankle can be more complex, particularly when the ankle is unstable or the bones have moved out of their normal positions. Bimalleolar and trimalleolar fractures frequently require surgical repair with plates and screws, followed by a period of immobilization and rehabilitation.
But even those labels don't tell the whole story. Two trimalleolar fractures aren't necessarily identical. The size and position of the fractures, whether the pieces have shifted, the condition of the joint and whether other structures were damaged can all affect treatment and recovery.
Displaced and Nondisplaced Fractures
Another term you're likely to encounter is displacement.
A nondisplaced fracture means the bone has broken but the pieces remain in or close to their normal position.
With a displaced fracture, the broken pieces have moved out of alignment.
That distinction can affect whether surgery is recommended, but it is only one part of the decision. Your surgeon considers the entire injury rather than a single word on an X-ray report.
The Injury May Involve More Than Bone
This is something that's easy to overlook when everyone is understandably focused on the fracture.
A bad twist, fall or impact can damage more than bone. Ligaments, tendons and other structures around the ankle can be injured at the same time.
A syndesmotic injury, often called a high ankle sprain, affects the ligaments that connect the tibia and fibula above the ankle joint. Mild injuries may be treated without surgery, while severe ones may require surgical stabilization.
Tendon injuries can occur as well. The peroneal tendons, which run along the outside of the ankle, help stabilize the joint during walking and other activity. They can become inflamed, torn or displaced. The Achilles tendon, which connects the calf muscles to the heel, can also be partially or completely torn.
Sometimes these injuries occur by themselves. Sometimes they accompany a fracture.
That can become particularly important later in recovery. A healed bone doesn't necessarily mean that every structure injured in the original accident has recovered at exactly the same rate.
Not Every Serious Ankle Injury Is a Fracture
A severe ankle sprain can cause considerable pain, swelling, bruising and difficulty bearing weight — symptoms that can look a lot like a fracture. Severe sprains can also damage ligaments enough to cause long-term instability if they aren't properly treated.
The point isn't to diagnose yourself from a list of symptoms. It's almost the opposite: ankle injuries overlap enough that it's often impossible to know exactly what's wrong without a medical examination and, when appropriate, imaging.
MY TAKE ON IT
Years ago—in 1998—I had another serious ankle injury, one that also required surgery and a prolonged non-weightbearing period. (Yes, it also involved falling off of a horse. I realize there may be more than one trend here.)
Immediately after my injury, I went to the emergency room, where after an X-ray, they told me it wasn’t fractured. I was thrilled to hear that, as I assumed that since it was “just a severe sprain” that I would quickly be back in action.
Yet I was completely unable to stand on it and the pain was off the charts. And after I “healed,” my ankle would often pop in an agonizing way. It became clear that it wasn’t going to go away on its own.
It turned out that my peroneal tendon was not only subluxating—the pop I felt—over the ankle bone (the lateral malleolus), but that it was ripped in two pieces and living on both sides of the bone.
A severe soft tissue injury like the one I had can be more debilitating and harder to heal than a simple, nondisplaced bone fracture. Bone healing for an uncomplicated fracture is often measured in weeks; recovery from a severe soft-tissue injury may take months and can still result in a permanent loss of full mobility or strength.
WORTH KNOWING
The name of your fracture is only the beginning of the story.
If you have access to your X-ray or CT report, operative report or surgeon's notes, you may see terms you didn't absorb when you were first injured. Pain, fear, medication and the shock of suddenly being unable to walk aren't ideal conditions for an anatomy lesson.
But it can be useful to understand exactly what you injured and what was repaired.
You don't need to become an orthopedic expert. You just need enough information to understand your ankle.
ASK YOUR SURGEON
If you're not completely sure what happened to your ankle, ask. Useful questions include:
Exactly which bone or bones did I break?
Was my fracture displaced or nondisplaced?
Was my ankle considered stable or unstable?
Was the ankle joint dislocated or out of alignment?
Did I injure the syndesmosis or other ligaments?
Were any tendons damaged?
Was there other damage inside the joint?
If I had surgery, what exactly was repaired?
Is there anything about my particular injury that could make recovery longer or more complicated?
Are there symptoms later in recovery that you would want me to report?