External malleolus fracture: causes, diagnosis and treatment

Causes of external malleolus fractures

Sports accidents

Sports accidents are a leading cause of external malleolus fractures. These incidents often occur during sports that require sudden movements or quick changes of direction, such as football, skiing, or basketball. When landing poorly after a jump or with a quick pivot, the ankle joint can undergo excessive strain, especially rotational, leading to an external malleolus fracture. Athletes are therefore particularly vulnerable to this type of injury, especially without proper equipment or with insufficient physical preparation. Hikers are also at risk for external malleolus fractures, as the terrain is often uneven with holes in which the feet can get stuck with a rotational mechanism of the ankle above.

Falls and missteps

A simple fall or misstep can also be the cause of an external malleolus fracture. Whether going down the stairs, tripping on an uneven sidewalk, or even during daily activities, falls represent a significant risk. These accidents can cause excessive twisting of the ankle, resulting in a fracture. Slippery surfaces or poorly lit environments increase this risk, making it essential to maintain safe living conditions to minimize hazards.

Lifestyle-related risk factors

Certain lifestyle-related risk factors can predispose individuals to external malleolus fractures. Among these, obesity and lack of physical activity are noteworthy. Excess weight puts additional pressure on the joints, including the ankles, increasing the risk of injury during impact or sudden twisting. On the other hand, weak musculature may not sufficiently stabilize the joints, making the ankle more exposed to fractures during normal activities or exercise.

Wearing inappropriate footwear can also contribute to the risk of fractures. Shoes that do not provide adequate support or are worn out can increase the likelihood of falls and ankle twists, particularly during sports or walking on uneven surfaces.

Understanding the causes and risk factors is important for preventing external malleolus fractures. Paying special attention to protective equipment, proper physical preparation, and a safe environment are essential measures to reduce the risk of this common but often preventable fracture.

Diagnosis of a fracture of the external malleolus

The diagnosis of an external malleolus fracture is important to determine the appropriate treatment and ensure optimal recovery. The diagnosis is suspected during the clinical examination and confirmed by medical imaging.

The clinical examination

During the first consultation, the specialist inquires about the injury mechanism and performs a detailed physical examination. This includes assessing pain, swelling, bruising, and visible deformity of the ankle. The doctor looks for specific physical signs that could indicate an external malleolus fracture, possibly associated with other injuries, particularly in the internal ligamentous structure of the ankle and the syndesmosis.

An essential aspect of this examination is palpation, where the doctor gently presses on different parts of the ankle to identify areas of acute pain, which helps localize the fracture and any potentially associated injuries. Depending on the symptoms and the results of this initial exam, the specialist may recommend imaging tests to confirm the diagnosis.

Medical imaging

Medical imaging plays a crucial role in accurately diagnosing external malleolus fractures. In the presence of a swollen, enlarged ankle with bruising, it is essential to take X-rays of the ankle even if the pain is not very severe. X-rays are an extension of the clinical examination; they allow clear visualization of the ankle bones, analysis of the bone structure, detection of fractures and possible displacement, as well as the search for indirect signs of associated injuries.

In some cases, when X-rays are inconclusive or if the doctor suspects complications, other forms of imaging may be used:

• Computed Tomography (CT scan), provides a more detailed, three-dimensional image of the bone structure, which is beneficial for planning possible surgical intervention.
• Magnetic Resonance Imaging (MRI) is useful for assessing injuries to the soft tissues surrounding the fracture, such as ligaments and tendons, which are not visible on X-rays.

These complementary imaging techniques provide important information that guides the management and treatment of the fracture. By combining the results of clinical examinations and medical imaging, specialists can develop a treatment plan tailored to each patient.

Available treatments for external malleolus fracture

The management of a fracture of the lateral malleolus varies depending on the severity of the injury and any associated lesions. In the vast majority of cases, we recommend surgical treatment for a fracture of the lateral malleolus because it is very frequently displaced. We do not tolerate any displacement of the fracture, as it is much more difficult to treat a fracture that has healed in a poor position, known as a malunion. Surgical treatment involves stabilizing the fracture with osteosynthesis material such as a screwed plate, thus promoting bone healing and limiting the duration of pain. During a surgical procedure on the ankle for a fracture of the lateral malleolus, we systematically combine osteosynthesis with ankle arthroscopy because:

• Joint lavage allows drainage of the intra-articular fracture hematoma, which is potentially toxic to the cartilage.
• Removal of small osteochondral fragments released at the time of the trauma is possible.
• Arthroscopy is the most reliable method to test the syndesmosis and stabilize it if it is unstable.
• Arthroscopy makes it possible to identify and treat tibial and talar cartilage lesions.
• The detection and treatment of any associated external and internal ligament lesions are performed by arthroscopy.
• The risk of surgical complications, which is always possible, is not increased when arthroscopy is combined with osteosynthesis.

Non-surgical treatment

For strictly non-displaced fractures, orthopedic (non-surgical) treatment can be sufficient. This type of treatment may include:

• Immobilization: Using a splint, cast, or orthopedic boot helps keep the bones in position for natural healing.
• Rest: Avoiding putting weight on the fractured ankle is important to prevent any displacement of the fracture.
• Medication: Anti-inflammatories and painkillers may be prescribed to manage pain and inflammation.
• Preventive anticoagulation: Preventive anticoagulants should be prescribed throughout the period of immobilization.
• Elevation and ice: These measures help reduce swelling and relieve pain.

In case of orthopedic, non-surgical treatment, our preference is to immobilize the fracture in a plaster boot for a period of 5 to 6 weeks. This helps limit the risk of fracture displacement and promotes the healing of any associated ligament injuries that may not be detected during physical examination due to the pain caused by the fracture.

Surgical intervention

In the case of a displaced fracture of the lateral malleolus, a surgical intervention is necessary. Several surgical techniques may be used or combined depending on the fracture and any associated injuries:

• Open reduction and internal fixation: This procedure involves repositioning the bone fragments and fixing them with screws and plates.
• Ankle arthroscopy: Used to assess and repair lesions associated with the fracture of the lateral malleolus of the ankle.
• Percutaneous surgery: In trauma cases, we use a percutaneous syndesmotic stabilization technique with a double button system when it is unstable.

The decision to proceed with surgery depends on many factors, including the patient's age, activity level, and presence of pre-existing medical conditions.

Rehabilitation and physiotherapy

After surgical or orthopedic treatment, rehabilitation following a fracture of the lateral malleolus is important for regaining ankle function. The rehabilitation program may include:

• Strengthening exercises: To restore muscle strength and ankle stability.
• Manual therapy: Techniques used by physiotherapists to improve movement and reduce pain.
• Patient education: Advice on pain management and prevention of future injuries.

Each phase of rehabilitation is tailored to the individual progress of the patient, with the ultimate goal of returning to daily activities without pain or limitation.

Recovery time after an external malleolus fracture

Phases of Rehabilitation

The duration of rehabilitation for a lateral malleolus fracture can vary greatly depending on the individual and the characteristics of the fracture and any associated injuries. Generally, the rehabilitation process is divided into several essential phases:

• Rest and healing phase: Immediately after treatment, whether surgical or not, a period of rest is essential. The use of crutches, an orthopedic boot, or a plaster cast is necessary to avoid putting weight on the injured ankle.
• Mobility recovery phase: Under the supervision of a physiotherapist, gentle flexion and extension exercises will help restore mobility without compromising bone healing and ligament recovery.
• Muscle strengthening: Strengthening exercises are then introduced to stabilize the ankle.
• Return to daily and sports activities: This final phase aims to resume activities while continuing strengthening exercises until the ankle regains its strength and mobility.

Tips for Effective Recovery

To optimize fracture recovery, here are some practical tips:

• Strictly follow your doctor's instructions: Each step of rehabilitation is important, and it is necessary to be diligent to achieve the best functional outcome.
• Stay active within pain limits: While rest is important, maintaining some activity, such as gentle ankle movements, can promote better healing.
• Use pain reduction methods: Ice application, elevating the ankle, and anti-inflammatory medications can help control pain and inflammation.
• Commit to physiotherapy: A physiotherapist specialized in ankle injuries can provide you with personalized exercises.