FRACTURE OF THE ANKLE
OPEN REDUCTION INTERNAL FIXATION
Fractures of the ankle range from relatively minor twisting injuries to those which are associated with violent disruption of the ankle, which may occur in motor vehicle accidents and falls from a height.
There are two different mechanisms of injury which have different effects on the structure of the ankle.
The one is where there is a twisting mechanism where the body rotates around the foot and the other is where there is a crushing type mechanism where there is an impact of some sort on the foot, for example in a motor vehicle accident.
Those with severe impact from motor vehicle accidents and falls from a height have the worst prognosis since there is often damage to the cartilage lining of the ankle.
The ankle anatomy
The ankle consists of the inner aspect of the tibia (the medial malleolus) the outer aspect of the ankle (the fibula), and the bone underneath the ankle (the talus). There are many different varieties and grades of severity of ankle fractures.
These may involve only the medial malleolus, the fibula, or both bones (which is called a bi-malleolar fracture).
At times, the talus may completely pop out of the ankle joint associated with the fracture, in which case we call this a fracture dislocation.
A more severe form of this injury is called a PILON fracture which often requires a 2 stage procedure with the first stage allowing for the soft tissue injury to settle by placing the pins on the outside of the leg crossing the ankle for 10-14 days at which point these will be removed and a definitive reconstruction will be performed on the inside of the ankle.
TREATMENT OF THE ANKLE FRACTURE
- If the shape and anatomy of the ankle is not accurately restored, the cartilage lining of the ankle is disturbed which will inevitably lead to arthritis.
- The goal of treating all ankle fractures is to reposition the bones in some way so as to prevent the occurrence of the arthritis.
- More minor ankle fractures can be treated in a boot or a cast without resorting to surgery.
- The MAJORITY of ankle fractures however DO REQUIRE operative treatment.
- Surgery is performed with incision(s) on one or both sides of the ankle and sometimes even down the back of the ankle.
- Screws and/or a metal plate are inserted into the medial malleolus and the fibula in order to accurately restore or reduce the fracture alignment.
- Occasionally if the fracture is very serious, we will use a small cage (called an external fixator) in addition to a plate and screws.
Postoperative recovery: general facts
- Following surgery, a bandage with plaster is applied to the ankle if I am worried about swelling until the stitches are removed and the wound inspected in approximately two weeks or a cast is applied straight away for 6 weeks.
- You can drive if the right ankle is fractured by 3 weeks and much later if it is the right ankle provided there is no swelling and pain is controlled.
- No walking on the foot is permitted until 3-4 weeks or until the cast feels loose.
- You may experience a variety of sensations whilst in the cast consisting of sharp shooting, dull aches, electric shocks, throbbing, sensation of itching and these are all normal and you should not panic.
- You will also be placed on DVT prophylaxis as there is a risk of blood clots shooting to the lungs with this procedure for a period of 6 weeks.
- Cast will be removed at 6 weeks, and then you will be in a walking boot.
- Exercise activities are initiated in a swimming pool at 6 weeks, on a stationary bike at 8 weeks, and on machines supervised by a physical therapist thereafter.
- Physical therapy exercises, swimming and biking are important as part of the recovery process to maximize recovery.
- It will take about 3 months before the ankle starts to feel comfortable and swelling will persist for about 6-9 months.
- Sometimes hardware must be removed at a later stage should irritation occur.
Specific post-operative recovery
- Foot is wrapped in a below knee cast.
- Elevate the leg on some pillows when awake however when sleeping elevate the base of the bed with 2 bricks or thick books so that the limb does not fall of the pillow at night and you wake up swollen.
- Take pain and DVT prophylaxis medication as prescribed.
- Expect numbness in foot 4-12 hours, followed by pain for usually one more day.
- Do not allow foot to hang down.
- If you are travelling, move the toes as much as possible to stimulate the calf muscle however travel during this time is not advisable.
- First follow-up in the office.
- Cast inspection for any possible complications or irritable areas +- adjustment of cast.
- Start full weight-bearing in cast with post-operative shoe and crutches initially to pain and swelling.
- Can allow foot to hang down at 3 weeks provided no pain and swelling occurs.
- Cast is removed by my dressing Sister and wound inspected.
- Control x-ray taken.
- If incision is dry and completely healed, swimming is permitted for rehabilitation purposes taking care to not jump in the pool or apply any unnecessary force.
- Gentle exercise on bicycle with no resistance or swimming with flippers permitted preferably guided by physiotherapist.
- At this stage a removable Moon boot is fitted and foot is prevented from inverting or everting and must be used for 6 weeks for any form of walking however patient does not need to sleep with this boot.
- 30lbs/13.63kgs body weight on the leg is allowed 5 minutes twice a day when washing/bathing.
- If swelling is problematic you may require the use of a compression sock.
- Start physical therapy under supervision with my protocols and this will focus on scar desensitisation and joint range of motion mostly.
- More vigorous exercise with Biokineticist for the next 8-12 weeks in order to achieve strength within 10% of the unaffected side hence clearing you for return to sport.
- Can discontinue boot at this stage and use a shoe with a supportive sole.
- Flat running on treadmill by 3 months.
- Followup in my consultation rooms.
- Control x-ray is taken.
- Photographs and video taken of range of motion and strength.
- Cutting sports by 4-6 months.
- May require gait analysis and custom orthotics to be made on an individual basis.
- Patient is usually discharged at this stage.
- Patient outcome score taken.