Anatomy of the ankle
The ankle involves two joints - one on top of the other. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues and ligaments.
The top ankle joint is composed of 3 bones:
• Shinbone (the tibia)
• Lower leg bone (the fibula)
• Anklebone (the talus)
The leg bones form a pocket around the top of the anklebone that lets the foot bend up and down.
Right below the ankle joint there is another joint called the subtalar. This is where the anklebone is connected to the heelbone or the calcaneus. The joint enables the foot to move from side to side.
Three sets of fibrous tissues connect bones and provide stability for the joints. The knob-like bumps that you can feel on the side of the ankle are actually the ends of the lower leg bones. The bump on the outside of the ankle (aka lateral malleolus) is a part of the fibula and the small bump on the inside of the ankle (called medial malleolus) is a part of the shinbone.
Symptoms of foot fracture
Any of the three bones of the ankle joint can break as a result of a fall, accident or other ankle trauma.
Every injury to the ankle should be examined by a doctor.
Symptoms of a fractured ankle may include:
• Severe pain
• Swelling
• Bruises
• Ankle and foot is tender to the touch.
• Patient is unable to put weight on the foot
• Visible deformities or dislocation
A broken ankle can also involve some damage to ligaments.
Ankle fractures: Treatment and rehabilitation
If the fracture is stable, i.e. without any damage to ligament or mortise joint, it is usually treated with a cast or braces. It usually takes 6 weeks or more for a broken ankle to heal. It may take several months before the injured person can return to their normal routine regarding movement, sports, etc.
In cased any ligaments are torn or the fracture has created a loose bone fragment that is irritating the joint, surgical operation may be needed.
Plates, metal/absorbable screws, staples/tension bands may be used to hold the bones together.
Fracture of the talus bone
The talus is a small bone placed between the heelbone (or calcaneus) and the two bones of the lower leg (the tibia and fibula). The talus meets the bones of the foot and forms the subtalar joint. This joint is crucially important for walking on uneven surface.
The talus helps transfer the weight and pressure forces across the ankle joint.
Most injuries to the talus result from motor vehicle accidents. Falls from heights can also injure it.
Such traumatic injuries are often associated with damage of the lower back.
Ankle fracture: Signs and symptoms
Most talar fractures (fractures (of the talus) are usually accompanied by:
• Severe pain
• Inability to bear body’s weight
• Swelling
• Tenderness
A fracture breaking through the skin means increased infectious risk.
Diagnosis
Confirming the diagnosis will need your doctor to examine the foot and ankle and ask you to describe how your injury has occurred. X-rays of your foot and ankle will be needed. In some cases X-ray will not show fractures and you will need a CT (computed tomography) scan.
Such diagnostic tests help pinpoint the location of the fracture and show whether the bones are still aligned (non-displaced fracture) or have shifted out of place (a displaced fracture). The physician will check for function of the nerves in the foot to ensure that there is no damage and will also make sure that blood is flowing to the toes.
Treatment
A talar fracture that is left untreated or that doesn't heal properly will later cause problems. Your foot function may be impaired, you may develop arthritis and chronic pain, and the bone may collapse.
Immediate first aid treatment:
First aid for talar fracture is applying a padded splint around the back of the foot and leg from the toe to the upper calf. Elevate the foot above the level of the heart. Apply ice for 20 minutes every hour until you can see a doctor.
In some rare cases, if x-rays show that the bones have not moved out of alignment, a talar fracture can be treated without surgery and you will have to wear a cast for at least 6 to 8 weeks and not put any weight on the foot for the time. Most fractures of the talus require surgery tough. This is needed to minimize later complications. An orthopedic surgeon will realign the bones and use metal screws to hold their pieces in place. In case of small fragments of bone, they may be removed. Bone grafts are used to restore the structural integrity of the joint.
After a surgery, the injured foot will be put in a cast for 6 to 8 weeks. You will not be able to put any weight on the foot for at least 3 more months.
At the healing stage your doctor orthopaedist may order x-ray or a magnetic resonance image (MRI) to check if blood supply to the bone is returning to normal. If the blood supply is disrupted, the bone tissue could die. This is a condition called avascular necrosis or osteonecrosis and could cause the bone to collapse.
Even if bones heal properly patients may still experience arthritis later.
Heel fractures
It takes a lot of force to break your heelbone (calcaneus). Motor vehicle accident or a fall from a height are possible scenarios.
Signs and symptoms
• Severe pain
• Inability to bear weight
• Pain may be centered on the outer side of the ankle, below the lower leg bone - fibula.
• Pain can also be focused in the heel pad, when trying to put weight on the injured foot
• Swelling
• Stiffness
See your doctor right away. If the bone heals improperly, severe problems may result afterwards.
Diagnosing a heel fracture
Your orthopedist will pinpoint the area of pain and tenderness and you will need to undergo x-ray of heel and ankle area. A computed tomography (CT) scan may also be needed.
Nerves pass close to the heelbone. Your physician shall check them functioning to make sure there is no damage
Treating heel fractures
If pieces of broken bone have not been pushed out of place after the injury you may not need any surgery:
Your foot will need to be elevated above the level of your heart and wrapped in a bulky, compressive dressing to keep the bones from shifting.
Ice packs help reduce swelling and pain. A medical professional may apply a splint until swelling goes down. This can take up to 3 weeks, followed by a removable splint. Your doctor may prescribe some exercises to maintain your flexibility and movement.
Healing takes at least 6 to 8 weeks, sometimes longer.
Surgical treatment
If bones have shifted out of place (a displaced fracture) surgery will most likely be needed. A metal plate and small screws are used to hold the bones in place. A bone graft may be used to aid in the healing of the fractures. The incision will be bandaged and a splint applied until it is healed. Then a removable splint is used so that the patient can begin exercising the joint.
You may experience stiffness. You won't be able to put any weight on your foot for approximately 10 weeks after surgery. When you begin walking, you may need to use a cane. It may take up to a year for the injury to heal completely.
Midfoot fracture (lisfranc)
Have you ever dropped a heavy box on the top of your foot? Or accidentally stepped in a small hole and fallen, twisting your foot? These two common accidents can result in a Lisfranc fracture-dislocation of the midfoot. This fracture gets its name from the French doctor who first described the injury.
Lisfranc injuries occur at the midfoot, where a cluster of small bones form an arch on top of the foot between the ankle and the toes. From this cluster, 5 long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.
Signs and symptoms
Lisfranc fracture-dislocations are often mistaken for sprains. The top of the foot may be swollen and painful. There may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. Lisfranc injuries are often difficult to see on X-rays. Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome, a build-up of pressure within muscles that can damage nerve cells and blood vessels. If the standard treatment for a sprain (rest, ice and elevation) doesn't reduce the pain and swelling within a day or two, ask your doctor for a referral to an orthopedic specialist.
Diagnosis
The orthopaedist will examine your foot for signs of injury. He may hold your heel steady and move your foot around in a circle. This motion produces minimal pain with a sprain, but severe pain with a Lisfranc injury. If your initial X-ray did not show an injury, the orthopaedist may request several other views, including comparison views of the uninjured foot and stress or weightbearing X-rays. In some cases, a computed tomography (CT) scan or magnetic resonance image (MRI) may be necessary to confirm the diagnosis.
Treatment
Treatment for a Lisfranc injury depends on the severity of the injury. If the bones have not been forced out of position, you will probably have to wear a cast and refrain from putting weight on the foot for about 6 weeks. When the cast is removed, you may have to wear a rigid arch support. Your orthopaedist will also recommend foot exercises to build strength and help restore full range of motion.
Often, operative treatment is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, you will have to wear a cast and limit weightbearing on the foot for 6 to 8 weeks. A walking brace may be prescribed when the fixation devices are removed. You may also have to wear an arch support and a rigid soled shoe until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.
It is important to follow your doctor's orders and refrain from activities until you are given the go-ahead. If you return to activities too quickly, you may easily suffer another injury, resulting in damage to the blood vessels, the development of painful arthritis, and an even longer healing time.
Stress Fractures of the foot and ankle
Stress fractures are a type of overuse injury. These tiny cracks in your bones develop when your muscles become overtired (fatigued) and can no longer absorb the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones, creating a small crack or fracture.
Stress fractures also can occur with normal usage if osteoporosis or some other disease weakens your bones and leaves them vulnerable. These fractures are often called "insufficiency fractures" because there isn't enough bone to withstand the normal stress of daily use.
Most stress fractures occur in the weight-bearing bones of the foot and lower leg. The most commonly affected site is the second or third of the long bones (metatarsals) between the toes and the midfoot. Stress fractures also can occur in the heel, the outer bone of the lower leg (fibula) and the navicular, a bone on the top of the midfoot.
Causes of stress fractures
Doing too much too soon is a common cause of stress fractures. Runners who have been confined indoors for most of the winter may want to pick up where they left off at the end of the previous season. Instead of starting slowly, they try to match their previous mileage. The result could be stress fractures in the foot and ankle.
Improper sports equipment, such as shoes that are too worn or stiff, also can contribute to stress fractures. A change of surface, such as going from a grass tennis court to one of clay or from an indoor to an outdoor running track, can increase the risk of stress fractures. Errors in training or technique are another cause of stress fractures. Some conditions, such as flatfoot or bunions, can change the mechanics of your foot and make stress fractures more likely to develop.
Insufficiency stress fractures result when the bone itself is weak. Conditions such as osteoporosis reduce the density and quality of bone matter, thus increasing the risk of fracture. Female athletes who experience irregular or absent menstrual periods may also have decreased bone density and an increased risk of stress fractures.
Treatment of stress fractures
Treatment will depend on the location of the stress fracture. Most stress fractures will heal if you reduce your level of activity and wear protective footwear for 2 to 4 weeks. Your orthopaedist may recommend that you wear a stiff-soled shoe, a wooden-soled sandal, or a removable short leg fracture brace shoe. Athletes should switch to a sport that puts less stress on the foot and leg. Swimming and bicycle riding are good alternative activities.
Stress fractures in the fifth metatarsal bone (on the outer side of the foot) or in the navicular or talus bones take longer to heal, perhaps as long as 6 to 8 weeks. Your orthopaedist may apply a cast to your foot or recommend that you use crutches until the bone heals. In some cases, you may need surgery so that the orthopaedist can insert a screw in the bone to ensure proper healing.
Toe and forefoot fracture
Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.
Types of fractures
Stress fractures frequently occur in the bones of the forefoot that extend from your toes to the middle of your foot. Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in training (such as running or walking for longer distances or times), improper training techniques or changes in training surfaces. Most other types of fractures extend through the bone. They may be stable (no shift in bone alignment) or displaced (bone ends no longer line up). These fractures usually result from trauma, such as dropping a heavy object on your foot, or from a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture.
Several types of fractures occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. An ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupts the blood supply to the bone. This injury may take longer to heal or require surgery.
Signs and symptoms
Pain, swelling, and sometimes bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk, but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than 2 or 3 days, or if pain interferes with walking, something could be seriously wrong; see a doctor as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. You could also change the way you walk (your gait), which could lead to the formation of painful calluses on the bottom of your foot or other injuries.
Diagnosis
The doctor will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell the doctor when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures, although a bone scan may occasionally be needed to identify stress fractures. Usually, the doctor will be able to realign the bone without surgery, although in severe fractures, pins or screws may be required to hold the bones in place while they heal.
Treatment
See a doctor as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the leg and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take an analgesic such as aspirin or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole.
Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for 3 to 4 weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your doctor or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.
The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor will "buddy-tape" the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you are diabetic or have peripheral neuropathy (numbness of the toes), do not tape the toes together. You may need to wear a rigid flat-bottom orthopedic shoe for 2 to 3 weeks.
If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom shoe. It could take 6 to 8 weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.
Surgery is rarely required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.
