Diagnostics
If an external ankle fracture is suspected, a classic x-ray is first made in two planes of the ankle joint to assess primarily the bony structures and to find out whether a fracture is actually present or just a sprained ankle. The X-ray image can also be used to plan the subsequent therapy and to determine whether surgery is necessary. A CT scan may also be necessary for a more precise assessment of the fracture. If there is a suspicion of a ligament structure injury, an MRI examination may also be necessary. However, this must always be decided in each individual case.
Therapy
Therapy by means of an operation on the external ankle fracture is always indicated when larger vessels or nerves have been damaged by the fracture and loss of sensitivity has occurred. The fracture must also be treated surgically if there is an open ankle fracture, i.e. if the skin has been destroyed by the fracture and possibly even bone parts protrude from the skin. There is a high risk of infection and the primary goal of the operation is to treat the surrounding soft tissue and muscles.
In addition, fractures of the outer ankle must also be operated on, where the bone fragments are shifted against each other, so that healing is not possible by the merging of these fragments. This is usually the case with fractures of the Weber C type. The aim of the operation is therefore to preserve the surrounding soft tissue and also to restore the exact anatomical conditions of the bones with regard to their axis, position and length.
In general, surgery on the external ankle fracture should be performed within six hours after the trauma, if possible, as otherwise the swelling will become too severe. If this time window is missed, it is necessary to wait until the swelling of the ankle has subsided, which can take from about three days to a week. Surgery for an external ankle fracture is performed under general anesthesia (general anesthesia).
First, after opening the skin over the ankle, the bone fragments are returned to their physiological position. In order to maintain this position of the bone fragments in relation to each other, they are fixed together using screws, wires and metal plates. Then a drainage, i.e. a tube to transport wound water out of the surgical area, is inserted and the wound is sutured.
After one to two days the drainage is pulled out again. After the operation it is necessary to immobilize the foot for six weeks, which is achieved by means of a plaster cast. It is also necessary to load the foot with only a part of the body weight, so crutches should be used when walking.
After removal of the cast, physiotherapy is very important. Approximately one year after the first operation, a new operation is necessary, in which the inserted screws and plates are removed again after the healing process is complete and the bones have grown together. A conservative treatment of an external ankle fracture, i.e. a non-surgical therapy, is used if the bone fragments are not displaced against each other and lie against each other in such a way that they can grow together well.
This is usually the case with Weber A type fractures and sometimes also with Weber B type fractures of the ankle that do not have any surgical indications, such as a nerve injury or an open fracture. In conservative therapy, the foot is relieved by immobilization to such an extent that the bone fragments can grow together again. In the past, immobilization of the foot was usually achieved by means of a plaster cast, which had to be worn for six weeks.
Nowadays, however, support bandages or so-called aircast splints are more commonly used, in which, in addition to the function of immobilizing the foot, an air cushion padding is also provided to absorb impacts or forces acting on the ankle. Immobilization in Aircast or splints usually takes place after the swelling of the ankle has subsided and then lasts for six weeks, as with a cast. In the case of uncomplicated fractures of the Weber A-Type, the splinted foot can immediately be fully loaded again, which has enormous advantages for the quality of life and mobility.
In the case of more complicated fractures, which are treated conservatively, only a partial load should be placed on the foot in addition to immobilization, i.e. no load should be placed on the foot due to full body weight. Crutches are used for about four weeks. After an x-ray check of the foot, in which it is ensured that the bone fragments are in good position to each other and have possibly even partially grown together, the foot can then be loaded with the full body weight in this case as well and the crutches are no longer needed.
In the conservative treatment of an external ankle fracture, the so-called PECH rule is also applied, in which the principles of rest, ice, compression and elevation are important. Finally, adequate pain therapy plays an important role in the treatment of an external ankle fracture without surgery, which is achieved, if necessary, with the help of painkillers such as Diclofenac. – Pausing (P) after the injury is ensured by splinting the foot.
- Additionally, cooling the ankle with ice (E), which should be wrapped in towels to prevent direct skin contact and thus frostbite, helps to alleviate the pain of the ankle. The cooling also helps to reduce swelling. – Compression (C) using an elastic bandage or splint also helps to prevent swelling. – Raising the foot (H) also helps to protect it and prevents the swelling from becoming excessive.
