Ankle Fracture

Also known as: Broken ankle, Ankle bone fracture, Fracture of the ankle, Malleolar fracture, Bimalleolar ankle fracture, Trimalleolar ankle fracture, Distal fibula fracture (lateral malleolus fracture), Distal tibia fracture (medial malleolus fracture)

Last updated: December 18, 2024

An ankle fracture is a break in one or more bones of the ankle joint, most often the distal tibia or distal fibula, and less often the talus. It can range from a small stable crack to an unstable, displaced pattern that may involve malleoli or ligament disruption and affect joint alignment. Symptoms include ankle pain, rapid swelling, and bruising. Management may include splinting or casting. Stable nondisplaced fractures can often heal with immobilization and rehabilitation.

Key Facts

•An ankle fracture involve a break in one or more bones forming the ankle joint, most the distal tibia and distal fibula, and less the talus
•Ankle pain that be severe at onset and worsens with weight-bearing or ankle motion
•Diagnosed through history, physical exam, and imaging
•First-line treatment includes exercise, weight management, and activity modification

What It Is

An ankle fracture may involve a break in one or more bones forming the ankle joint, most commonly the distal tibia and distal fibula, and less commonly the talus. The injury can range from a small, stable crack to an unstable fracture pattern with displacement, comminution, or associated ligament disruption that can affect joint congruence. Fracture patterns may include malleolar fractures (medial, lateral, and/or posterior malleolus) and may occur with syndesmotic injury, which can alter ankle mortise stability. Because the ankle is a weight-bearing joint with articular cartilage surfaces, fractures can often be associated with swelling, soft-tissue injury, and a risk of post-traumatic osteoarthritis depending on alignment and cartilage involvement.

Affected Anatomy

This condition affects several structures in and around the joint:

•Distal tibia (including the tibial plafond)
•Medial malleolus (tibial medial malleolar process)
•Distal fibula (lateral malleolus)
•Posterior malleolus (posterior tibial lip)
•Talus (talar dome and body)
•Ankle mortise (tibiotalar joint space and alignment)
•Distal tibiofibular syndesmosis (anterior and posterior inferior tibiofibular ligaments)
•Deltoid ligament complex (medial ankle stabilizers)

Common Symptoms

Symptoms can vary in intensity and may change over time. Common experiences include:

•Ankle pain that may be severe at onset and can worsen with weight-bearing or ankle motion
•Swelling that can develop rapidly and may extend into the foot or lower leg depending on soft-tissue injury
•Bruising or discoloration that can appear around the malleoli and along the foot over hours to days
•Tenderness localized to the malleoli, distal tibia/fibula, or talus that can increase with palpation or stress maneuvers
•Difficulty bearing weight or inability to ambulate that may correlate with fracture stability and displacement
•Visible deformity or malalignment that can occur with displaced fractures or fracture-dislocations
•Reduced range of motion and stiffness that may reflect pain, joint effusion, or mechanical block
•Numbness or tingling that can occur with swelling-related nerve irritation or, less commonly, neurovascular compromise

Causes and Risk Factors

Multiple factors can contribute to the development of this condition:

Causes

•Twisting injury (rotational mechanism) during a fall, sports activity, or misstep that can produce malleolar fractures and may involve the syndesmosis
•Direct trauma such as a motor vehicle collision or impact injury that can cause comminuted fractures and soft-tissue damage
•Fall from height with axial loading that can transmit force through the talus to the tibial plafond and may contribute to complex fracture patterns
•Sports-related contact or rapid direction change that can combine inversion/eversion forces with rotation and can injure ligaments along with bone
•Low-energy fall in the setting of reduced bone strength that can contribute to fractures with relatively minor trauma

Risk Factors

•Participation in sports with cutting, jumping, or contact that can increase exposure to twisting and impact mechanisms
•History of prior ankle sprain or instability that can alter biomechanics and may increase susceptibility to injury
•Reduced bone mineral density or osteoporosis that can increase fracture risk with low-energy trauma
•Older age, which can be associated with balance changes and reduced bone strength
•High-energy occupational or recreational exposures (e.g., climbing, construction, motor vehicle travel) that can increase trauma risk
•Footwear or environmental factors (uneven surfaces, ice) that can increase slip and fall risk
•Conditions or medications associated with impaired balance or bone health that can increase fall risk or fracture susceptibility
•High body mass, which can increase mechanical load during falls and may influence injury severity

How It's Diagnosed

Diagnosis typically involves a combination of clinical assessment and imaging studies:

•Clinical history and mechanism assessment that can help estimate fracture pattern risk (rotation, axial load, direct impact) and associated ligament injury likelihood
•Physical examination that can include inspection for deformity, swelling, and skin compromise; palpation of malleoli, distal tibia/fibula, and midfoot; and assessment of range of motion limited by pain
•Neurovascular assessment that can include evaluation of distal pulses, capillary refill, skin temperature, and sensory/motor function to screen for compromise related to swelling or displacement
•Plain radiographs (X-rays) that typically include anteroposterior, lateral, and mortise views to evaluate fracture location, displacement, mortise alignment, and possible talar shift
•Stress radiographs or gravity stress views that can be used in selected cases to assess medial clear space widening and potential instability related to deltoid or syndesmotic injury
•Computed tomography (CT) that can better characterize complex, intra-articular, posterior malleolar, or comminuted fractures and can assist with surgical planning
•Magnetic resonance imaging (MRI) or ultrasound in selected scenarios that can help evaluate associated ligament, tendon, or cartilage injury when radiographs do not fully explain symptoms

Treatment Options

Treatment approaches range from conservative measures to surgical interventions, often starting with the least invasive options:

Self-Care and Activity Modification

•Initial immobilization with a splint or cast to limit motion and support soft-tissue recovery while fracture stability is assessed
•Activity modification and protected weight-bearing status that can be used depending on fracture stability, pain, and imaging findings
•Closed reduction for displaced fractures or fracture-dislocations to restore alignment, often followed by immobilization and repeat imaging to confirm position
•Elevation and cold application as supportive measures that can help reduce swelling and discomfort in the early phase
•Syndesmotic fixation (screws or suture-button constructs) when distal tibiofibular instability is present to support mortise stability
•External fixation in selected high-energy injuries or when soft-tissue swelling limits immediate internal fixation, often as a temporizing or staged approach
•Venous thromboembolism risk assessment and prevention strategies that can be considered in immobilized patients based on individualized risk factors and clinician evaluation

Medications

•Analgesic medications that may include acetaminophen or nonsteroidal anti-inflammatory drugs, with selection often influenced by individual health factors and clinician preference

Injections and Office-Based Procedures

•Open reduction and internal fixation (ORIF) using plates and screws for unstable, displaced, or intra-articular fractures to improve alignment and joint congruence

Surgery

•Physical therapy and rehabilitation that can focus on restoring range of motion, strength, proprioception, and gait mechanics after immobilization or surgery

Prognosis and Recovery

The course of this condition varies between individuals:

•Stable, nondisplaced fractures can often heal with immobilization and gradual rehabilitation, with functional recovery varying by age, activity level, and adherence to rehabilitation plans.
•Displaced or unstable fractures can have a longer recovery span and may require surgical stabilization to restore alignment and reduce the likelihood of chronic instability.
•Intra-articular involvement, malalignment, or cartilage injury can increase the likelihood of persistent stiffness, pain, or post-traumatic osteoarthritis over time.
•Soft-tissue swelling, blistering, or open fracture features can complicate timing and approach to definitive management and can influence recovery span.
•Return to high-impact sport or heavy labor can require a prolonged rehabilitation span, and residual symptoms such as swelling after activity can persist for months in some individuals.

Open Reduction and Internal Fixation (ORIF)(Procedure)
Closed Reduction (Fracture Reduction Without Incision)(Procedure)
Ankle Sprain(Condition)

Frequently Asked Questions

Common symptoms include: Ankle pain that may be severe at onset and can worsen with weight-bearing or ankle motion; Swelling that can develop rapidly and may extend into the foot or lower leg depending on soft-tissue injury; Bruising or discoloration that can appear around the malleoli and along the foot over hours to days; Tenderness localized to the malleoli, distal tibia/fibula, or talus that can increase with palpation or stress maneuvers; Difficulty bearing weight or inability to ambulate that may correlate with fracture stability and displacement.

Diagnosis typically involves: Clinical history and mechanism assessment that can help estimate fracture pattern risk (rotation, axial load, direct impact) and associated ligament injury likelihood; Physical examination that can include inspection for deformity, swelling, and skin compromise; palpation of malleoli, distal tibia/fibula, and midfoot; and assessment of range of motion limited by pain; Neurovascular assessment that can include evaluation of distal pulses, capillary refill, skin temperature, and sensory/motor function to screen for compromise related to swelling or displacement; Plain radiographs (X-rays) that typically include anteroposterior, lateral, and mortise views to evaluate fracture location, displacement, mortise alignment, and possible talar shift.

Treatment options range from conservative measures to surgical interventions, including: Initial immobilization with a splint or cast to limit motion and support soft-tissue recovery while fracture stability is assessed; Activity modification and protected weight-bearing status that can be used depending on fracture stability, pain, and imaging findings; Closed reduction for displaced fractures or fracture-dislocations to restore alignment, often followed by immobilization and repeat imaging to confirm position; Analgesic medications that may include acetaminophen or nonsteroidal anti-inflammatory drugs, with selection often influenced by individual health factors and clinician preference; Elevation and cold application as supportive measures that can help reduce swelling and discomfort in the early phase.