Fracture

General : 

Ankle fractures, most often resulting from sudden tackles or impacts, require emergency treatment and the quickest possible reduction if the ankle is dislocated. This reduction is crucial to prevent hypo-perfusion and/or nerve damage. Wound haematoma and wound edge necrosis are the most common complications and the postoperative infection rate is 2%. Up to 10% of patients develop osteoarthritis of the ankle in the medium to long term. (1)

It also seems important to look at the syndesmosis during management for optimal anatomical reconstruction of the joint. Indeed, a syndesmotic lesion occurs in about 50% of Weber B fractures and in all Weber C fractures (4). (classification developed in the diagnostic section) 

Anatomically, what is the ankle ?

The talocrural (ankle) joint is the junction of three bony structures: the distal ends of the tibia and fibula (fibula) and the trochlea of the talus. 

The tibia and fibula are elastically linked in the ankle joint via the ligamentous structures of the syndesmosis (interosseous membrane, anterior, posterior and transverse tibiofibular ligaments) (5)(2). 

Strong collateral ligaments (3 bundles) stabilise the joint against lateral stress. Medially, there are 2 main bundles. 

How to make the diagnosis ?

First of all, it is essential to know the mechanism of injury and to contextualise what has happened. For some scientists, it is difficult to reliably distinguish an ankle fracture from a ligament injury on the basis of the initial physical examination alone. The findings only allow for a more precise orientation before a subsequent X-ray examination is performed. 

Clues to a probable ankle fracture are swelling, haematoma formation, tenderness to pressure on the medial and/or lateral malleolus or on the proximal head of the fibula (high fibular fracture, so-called Maisonneuve injury). In addition, any other associated bony injury should be excluded by palpating the talus, calcaneus, navicular, mid-tarsal joint (Chopart) and the base of the fifth metatarsal for crepitus or local tenderness. 

As with all dislocated fractures, gross malposition of the joint is an indication for immediate reduction with manual axial traction under adequate analgesia, followed by splinting of the joint.

The criteria to be applied directly to guide or refute the diagnosis of fracture are based on the Ottawa criteria. 

• Inability to take 4 steps, either directly after the trauma or on examination
• Pain in the lower 6 cm of the medial or lateral malleolus
• Pain at the base of the 5th metatarsal (styloid process) 
• Pain in the navicular bone 

On arrival at the emergency room, the X-ray examination will show the pre-diagnosis already made. Three radiographs (anterior-posterior, lateral and mortise) are required to assess the bone and joint status of the ankle (7). Weber establishes 3 categories of fractures which are defined in the literature according to the position of the fracture line in relation to the syndesmosis. 

• Type A: subligamentary (below the syndesmosis)
  
• Type B: inter-ligamentary (at the level of the syndesmosis)
  
• Type C: supra-ligamentary (above the syndesmosis)

What treatment should be applied ?

In the field, an immediate inspection of the undressed lower limb must be carried out by the medical staff or the rescue team. The soft tissue inspection should include perfusion status and possible detection of significant nerve damage. In case of obvious malposition of the limb, immediate reduction under painkillers is essential to avoid necrosis or delay of the operation afterwards. Equally important, cooling of the joint should be undertaken with care, or not at all in the case of an open fracture, to avoid cold injury to the soft tissues (which could affect the nerves, skin or cause atrophy of the muscles involved) (8)

The decision to operate or not depends on the type of fracture (bone stripping, dislocated, open…) but also on the surgeon and his habits. The objectives of surgery are always the smooth anatomical reconstruction of the joint surface and the protection of injured ligamentous structures to allow early postoperative functional therapy of the joint (1). Isolated unstable fractures of the lateral malleolus and bi- and trimalleolar fractures are usually always treated with internal fixation. Conservative treatment of unstable ankle fractures results in short-term loss of function and long-term development of osteoarthritis (10).

On the advice of the physician, a period of immobilisation is required for several weeks. In principle, any stable fracture with non-displaced or slightly displaced fragments can be treated conservatively. These injuries are now preferentially immobilised via orthoses or walking boots to ensure early function combined with full weight-bearing adapted to the pain. It is also important to keep this immobilisation at night and to use crutches to move around until the doctor or physiotherapist has given his or her opinion, since removing them too quickly could lead to compensations when walking, postural disturbances and also slow down the healing process. As and when necessary, the latter will allow the support to be put in place when walking, which must be done as quickly as possible, keeping in mind the patient’s sensations. If the patient is unable to put full weight on the ankle due to the type of fracture or pain, the administration of an antithrombotic drug during this period should be considered, in order to avoid the formation of a blood clot (9).

And what about rehabilitation ?

It is essential to carry out rehabilitation with a physiotherapist after the removal of the orthosis or walking boot. Early treatment reduces the risk of complications and, above all, allows for a much faster recovery of function, muscles and trophies. In patients in good physiological condition and without comorbidities, the objective is to restore the pre-injury anatomy with precision in order to obtain the best possible function and avoid the development of osteoarthritis (3). The aim is to return to the field as soon as possible. 

During treatment, it is important to regain the correct range of motion as quickly as possible, which is naturally reduced after several weeks of immobilisation. The stabilising muscles of the ankle (long and short fibular, posterior tibial, etc.) must also be strengthened, but above all, a great deal of proprioception work must be done. It is interesting to include as many exercises as possible related to the patient’s sporting activities, while the resumption of running is done very gradually and with respect for the pain threshold. 

With all this information, how can we prevent ankle fractures ?

Preventing fractures in football cannot prevent or considerably reduce the risk of injury, as these injuries usually occur as a result of tackles or blows. They are caused by external stresses on the body that exceed its normal capacity to resist. However, there are a few ways to reduce the incidence of this type of injury. Indeed, a sufficient diet in terms of calories, proteins and calcium in particular would make it possible to increase the solidity of the bone tissue. The prevention of fractures outside of external contact can be achieved by working on a variety of supports, with good motor control of the lower limb to be able to cope with various landing constraints. As mentioned above, strengthening the stabilising muscles of the ankle should also be taken into consideration. These lines of thought need to be studied more closely, but it still seems very complex to base studies on isolated facts such as violent tackles and to study statistically the effects of nutritional influences or various training on constraints of different intensities. 

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