Broken ankle

Ankles break in the most ordinary way: a foot turns over on a kerb, on ice, on the last step of the stairs. Straight afterwards it is almost impossible to tell a fracture from a sprain by eye, because swelling, bruising and pain look the same in both, and being just about able to put weight on the foot does not rule a break out. An X-ray settles it, and there is no sense in putting it off: the bones of the ankle carry the weight of the whole body, and if they knit in a shifted position they leave pain and stiffness for years.

When urgent help is needed straight away

Some signs mean the injury goes to the emergency department at once, without waiting for morning and without trying to walk on it.

• the foot sits at an unnatural angle, twisted or shifted relative to the leg;
• bone is visible in the wound, or there is an open wound over the fracture;
• the toes have turned white or blue, feel cold, or have lost sensation;
• the pain is so severe that it is hard to speak or think, and it does not ease at rest;
• putting any weight on the foot is impossible;
• the leg swells fast and heavily, and the skin becomes tight and shiny.

Driving in this state is out of the question: ask someone to take you, or call an ambulance. Bring a list of the medicines you take, and eat and drink nothing until you have been assessed, because a displaced break may need sedation or an operation, and that requires an empty stomach.

Fracture or sprain: what can be judged before the X-ray

There is no certainty without an X-ray, but there are landmarks by which a doctor decides whether a film is needed at all, and they are easy enough to check yourself.

• Pain when pressing on the bony prominence, the ankle bone on the inner or outer side, along its back edge and its tip. In a sprain the tenderness is lower and more towards the front, in the soft tissues.
• Being able to take four steps immediately after the injury and again during examination. If you cannot, a film is needed.
• Pain when pressing on the outer border of the foot near the base of the little toe or in the middle of the arch: a bone breaks there that is regularly forgotten in ankle injuries.

Swelling and bruising barely help the decision: a torn ligament produces both just as readily as a crack in the bone. Conversely, plenty of people can walk on an undisplaced fracture, which is precisely why such injuries get carried around for weeks as a bad bruise.

What to do in the first hours

Until you are seen, the task is simple: reduce the swelling and do not let the fragments shift.

• Keep weight off the leg, and if crutches or a stick are to hand, use them.
• Raise the leg above the level of the heart: cushions under the calf, and lying down works better than sitting.
• Cold for 15–20 minutes every two to three hours on the first day. Ice or a bag of frozen vegetables always through a towel, never straight onto bare skin.
• Take rings off the toes, bracelets off the ankle and tight shoes off before the swelling builds.
• Wrap loosely with an elastic bandage, from the bottom upwards, but only if the foot is in line. With an obvious deformity, bandage nothing and try to straighten nothing.
• If there is bleeding, press a clean cloth to the wound.
• Paracetamol will do for the pain; anti-inflammatory tablets or gel are also used, but with the diagnosis still open and surgery possible they are worth checking with a doctor.

For the first two days do not warm the area, do not rub it with heating ointments or alcohol and do not massage it: that increases bleeding into the tissues and swelling.

The fractures most often missed

The ankle is injured in a single movement, but the ankle is not always the only thing that breaks. A few situations are worth keeping in mind, since they are found late again and again.

• A fibula fracture up near the knee. The foot twists, the ligaments at ankle level tear, and the bone breaks high up, almost at the knee. The person complains about the ankle, the film covers only the ankle, and the high fracture stays invisible. The clue is pain on the outer side of the lower leg, below the knee, after the foot has turned over. Say it out loud even if it seems trivial next to a swollen ankle.
• The base of the fifth metatarsal. The outer border of the foot hurts, roughly halfway between the heel and the little toe. It breaks in the same twist, and an ankle film does not always include the edge of the foot.
• The talus and its processes. A common injury in falls from a height and in snowboarding. Swelling is marked, yet the fracture line may not show on a plain X-ray, and a CT scan is sometimes needed.
• A tear of the ligament between the two leg bones. The bones separate and the joint becomes unstable. If that is not spotted, a cast does not help: surgery is required.
• A stress fracture. It comes not from one movement but from repeated loading: pain builds over weeks in runners and after a sudden increase in training. On an early film it often cannot be seen.
• The diabetic foot with reduced sensation. It can be warm, swollen and almost painless while the bones are already breaking down. Swelling like that without a clear injury is a reason to be seen quickly rather than to wait.

Children have a particular feature of their own: growth plates do not appear as bone on a film, and damage there is easily mistaken for a sprain. So tenderness right over the ankle bone in a child is always assessed by a doctor, even when the X-ray looks normal.

How it is treated

First comes an X-ray in two views. If the picture is complicated a CT scan is added to show the joint surface. After that everything depends on whether the fragments are in place and whether the joint is stable.

• Undisplaced fracture with a stable joint: a walking boot, a brace or a plaster cast. Permission to bear weight varies from a complete ban to walking in the boot, and the doctor decides.
• There is displacement but no need to operate: the bones are put back under anaesthetic and held in a cast, after which a check film is taken.
• Unstable joint, displaced fragments or an involved joint surface: an operation with fixation by plate and screws. The metal stays in the bone permanently in most cases.
• Open fracture: urgent surgery with washout of the wound and antibiotics, with no delay, because of the risk of infection.

Check films are usually repeated after one or two weeks: even well-placed fragments sometimes move as the swelling goes down.

What to watch while the leg is immobilised

A cast and a rigid boot create risks of their own. Seek help urgently if the pain increases instead of settling and is not relieved by painkillers; if numbness, pins and needles or a bursting sensation appear; if the toes look pale, bluish or cold, or are hard to move. That is how pressure on the tissues shows itself, and there the clock runs in hours. The same applies to burning and pain at one spot under the dressing, a bad smell, discharge soaking through the cast and a fever: these point to skin damage or infection.

Clotting is a separate matter: a leg held still inside a cast raises the chance of it. Pain and tightness in the calf above the dressing and swelling of the thigh are warning signs, and if breathlessness, chest pain or coughing up blood come on suddenly, help is needed immediately.

The rest is more straightforward: keep the cast dry, push nothing underneath it to scratch the skin, move the toes and bend the knee several times a day, since that reduces swelling and stiffness.

How long healing takes and how to return to loading

Bone knits in six to eight weeks on average, but that is not the timescale for returning to your former life. Evening swelling, stiffness and pain on unfamiliar movements persist for several months more, and that is a normal course rather than a complication.

Once the immobilisation comes off the leg obeys badly: the muscles have weakened, the joint has lost range and the sense of balance suffers. Work with a physiotherapist, or exercises to their plan, brings back range, strength and steadiness. The last of those matters especially: without balance training, turning the ankle over again happens easily.

Healing is helped by simple things: stopping smoking, enough protein, calcium and vitamin D in the diet, and movement within what is allowed rather than complete rest. The timing of a return to running, jumping and contact sport is set by the state of the leg, not by the calendar.

One more thing. A fracture in someone over fifty after a minor injury, such as a fall from standing height, is a reason to check bone strength: quite often it is the first signal of osteoporosis. That question is taken up once the treatment of the fracture itself is finished.

Online consultation

In an online consultation the doctor will go through the circumstances of the injury and the symptoms, help work out whether an X-ray is needed and where to take that, and explain a report already issued when the wording is impenetrable. Remotely it is also convenient to deal with what begins after the cast: how much load to put through the leg, why the foot still swells by evening in the third month, which exercises to do and when to go back to sport. The urgent signs listed above are assessed in person: where displacement, pressure on the tissues or a clot is suspected, a video consultation is not the right tool.

This material is for information only and does not replace medical advice.