•A great deal of research has been conducted to deter-
mine the incidence of age related fractures particu-
larly in the elderly population. Barrett et al analyzed
medicare data in 1999 and found that ankle fractures
were the fourth most common fracture in the elderly
population (65–90 years of age). The study also
demonstrated that elderly Blacks were less likely than
Whites to fracture the ankle (Barrett et al, 1999).
PHYSICAL EXAMINATION
- The examination of the ankle should begin with a
thorough visual inspection noting abnormal swelling,
redness, or deformities. The physician should also
palpate the ankle to determine the extent of any
swelling, identify any abnormal bony prominences or
incongruities, determine specific areas of point ten-
derness or extreme pain, and evaluate the neurovascu-
lar status of the patient. - The neurovascular examination should include an
assessment of the dorsalis pedis and posterior tibial
pulses. Additionally, the physician should evaluate the
capillary refill, light touch, and two-point discrimina-
tion distal to the ankle. - Gross deformity of the ankle is a likely indicator of dis-
location, which should be reduced and splinted prior to
radiographic examination or further evaluation. - The physician will then evaluate the range of motion
of the ankle. The normal range of ankle motion is 30°
of dorsiflexion and 45°of plantarflexion. The range of
motion necessary for ankle functionality or ambula-
tion is 10°of dorsiflexion and 20°of plantarflexion
(Koval and Zuckerman, 2002). - It is important to evaluate the stability of the ankle
when suspecting a fracture. The squeeze test is per-
formed to rule out disruption of the tibiofibular syn-
desmosis. The squeeze test is performed by squeezing
the leg, approximating the tibia and fibula, at or
slightly above the level of the belly of the gastrocne-
mius. An indicator of syndesmotic disruption is pain
at the distal tibiofibular articulation when the squeeze
test is performed (Hopkinson et al, 1990). The physi-
cian should also perform an anterior-drawer to evalu-
ate the laxity of the complex ligamentous support
network of the ankle. Pain with dorsiflexion and
external rotation should also be noted as this may rep-
resent posterior bony injury or tendinous disruption.
RADIOGRAPHIC EXAMINATION
- The Ottawa ankle rulesare a valuable guideline in
determining the need for radiographic examination in
a patient suspected to have an ankle fracture.
Radiographic examination is required if the patient is
unable to bear weight, if the patient has pain with pal-
pation within 6 cm proximal or distal to the talar artic-
ulation, or if the patient has bony tenderness at the
posterior edge or tip of either malleoli (Stiell et al,
1993).- The ankle is best examined radiographically with an
anterior-posterior, lateral, and mortise view. Three
view radiographs demonstrate greater reliability when
compared to various combinations of two view radi-
ographs (Brandser et al). Abnormal radiographic find-
ings are greater than 2 mm of talar tilt (difference in
lateral and medial joint spaces in anterior-posterior
view), misalignment of the talar dome under the tibia
in anterior-posterior or lateral views, and a demon-
strated tibiofibular overlap of less than 10 mm in the
anterior-posterior view or the mortise view (Marsh
and Saltzman, 2001). Stress radiographs may be valu-
able, but are difficult to standardize. Though norma-
tive data is not adequately reported in the literature,
the Telos stress device is being used to standardize the
amount of stress about the ankle during routine radi-
ographic stress examinations. - Magnetic resonance imaging(MRI) is best suited for
the examination of the integrity of the ankle ligaments,
and a bone scan is often helpful to rule out osteochon-
dral lesions in patients with chronic ankle injuries.
CLASSIFICATION- There are three primary classification systems used to
define ankle fractures. The Danis-Weber classification
is based solely upon the fibula and the location of the
fracture in relation to the ankle mortise (Danis, 1949).
The Lauge-Hansen classification describes the ankle
fracture according to foot position and movement of
the foot in relation to the leg (supination-adduction,
supination-external rotation, pronation-abduction,
pronation-eversion, pronation-dorsiflexion). The most
common mechanism of ankle fracture is of the
supination-external rotation variety (Lauge-Hansen,
1950). Lastly, the A-O classification is based on the
level of the fibula fracture, medial malleolar involve-
ment, and syndesmotic disruption (Orthopedic
Trauma Association, 1996). A summary of the afore-
mentioned classifications can be found in Table 64-4.
TREATMENT- The goal of treatment of ankle fractures is to restore
the anatomic congruity of the ankle joint, promote
pain free restoration of range of motion, and to restore
and maintain fibular length.
380 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE