The articular surface of the ankle joint is smaller than that of the hip and knee joints, yet it bears significant weight and movement, making it prone to injury. It accounts for 3.83% of all fractures in the body and is more common in adolescents.

bubble_chart Etiology

Inversion (adduction) fracture

can be divided into three degrees.

Degree I: Simple medial malleolus fracture, with the fracture line extending obliquely upward and medially from the lower articular surface of the tibia, nearly vertical.

Degree II: With greater force, while the medial malleolus suffers an impacted fracture, the lateral malleolus experiences an avulsion fracture, known as a bimalleolar fracture.

Degree III: With even greater force, in addition to fractures of the medial and lateral malleoli, the talus impacts the posterior edge of the tibia, resulting in a posterior malleolar fracture (trimalleolar fracture).

Eversion (abduction) fracture

can also be classified into three degrees based on severity.

Degree I: Simple avulsion fracture of the medial malleolus, with a transverse or short oblique fracture line and a coronal fracture surface, usually non-displaced.

Degree II: Continued force causes the talus to impact the lateral malleolus, resulting in an oblique fracture of the lateral malleolus, i.e., a bimalleolar fracture. If the inferior tibiofibular ligament is torn along with the medial malleolus fracture, separation of the distal tibia and fibula may occur. In this case, the talus shifts outward, creating a torsional force at the lower end of the fibula above the syndesmotic ligament, leading to a fracture of the lower or middle third of the fibula, known as a Dupuytren fracture.

Degree III: Excessive force causes the talus to impact the posterior edge of the tibia's lower articular surface, resulting in a posterior malleolar fracture, i.e., a trimalleolar fracture.

External rotation fracture

occurs when the leg is stationary and the foot is forcefully rotated outward, or when the foot is stationary and the leg is forcefully rotated inward. The anterolateral part of the talus compresses the anteromedial part of the lateral malleolus, causing an oblique or spiral fracture of the distal fibula, which can also be divided into three degrees.

Degree II: Greater force causes rupture of the medial collateral ligament or an avulsion fracture of the medial malleolus, resulting in a bimalleolar fracture.

Degree III: Severe force causes the talus to shift laterally and rotate outward, impacting the posterior malleolus and resulting in a trimalleolar fracture.

Longitudinal compression fracture

occurs when falling from a height and landing vertically on the heel, leading to a fracture of the anterior tibial margin accompanied by anterior dislocation of the ankle joint. If the force is excessive, it may cause a comminuted fracture of the tibia's lower articular surface.

In cases of severe trauma resulting in a trimalleolar fracture, the ankle joint loses all stability and exhibits significant dislocation, known as a Pott fracture.

bubble_chart Diagnosis

Local swelling, tenderness, and dysfunction. During diagnosis, the mechanism of injury should first be analyzed based on the history of trauma, clinical symptoms, and the type of fracture shown on the X-ray.

bubble_chart Treatment Measures

The articular surface of the ankle joint is smaller than that of the hip and knee joints, but it bears more body weight than the hip and knee joints. Since the ankle joint is close to the ground, the stress from weight-bearing cannot be buffered. Therefore, the treatment of ankle joint fractures requires higher standards compared to other areas. The importance of anatomical reduction for ankle joint fractures is increasingly recognized. If the articular surface is slightly uneven or the joint space is slightly widened after a fracture, traumatic arthritis can occur. Regardless of the type of fracture, the treatment requires the saddle-shaped articular surface of the lower tibia (i.e., the ankle joint) to align perfectly with the talus. Additionally, the medial and lateral malleoli must restore their normal physiological inclination to accommodate the talus, which is narrower posteriorly and superiorly and wider anteriorly and inferiorly.

Non-displaced fracture

The ankle joint is fixed in a neutral position at 90° dorsiflexion with a lower leg cast. After 1–2 weeks, when the swelling subsides and the cast loosens, it can be replaced once. The cast is generally worn for 6–8 weeks.

AD

TCM's treatment of atopic dermatitis is more comprehensive, fundamental, non-toxic and effective than Western medicine's symptomatic treatment

1. Manual reduction and external fixation

The principle of manual reduction is to apply force in the opposite direction of the injury mechanism, pressing the displaced bone fragments back into place. For example, in the case of an eversion fracture, an inversion posture is adopted, with the foot maintained at 90° dorsiflexion while both hands compress the malleoli to achieve reduction. After reduction, the lower leg is immobilized with a cast for 6–8 weeks.

2. Surgical reduction and internal fixation

The treatment of ankle fractures demands anatomical reduction. For cases where manual reduction fails to meet therapeutic requirements, surgical intervention is often recommended.

(1) Indications a. Failure of manual reduction; b. Inversion fracture with a large medial malleolar fragment involving more than half of the lower tibial articular surface; c. Eversion-external rotation avulsion fracture of the medial malleolus, especially if soft tissue is interposed; d. Large fracture fragment at the anterior margin of the lower tibial articular surface; e. Failure of manual reduction for posterior malleolar fractures; f. Trimalleolar fractures; g. Old fractures with secondary traumatic arthritis affecting function.

(2) Surgical principles General principles include: a. Anatomical alignment of the ankle mortise; b. Rigid internal fixation to allow early functional exercise; c. Complete removal of bone and cartilage fragments from the joint; d. Surgery should be performed as early as possible.

(3) Methods for fractures at different locations a. Medial malleolar avulsion fracture: Fixation with screws is sufficient. If screws fail to provide adequate fixation, Kirschner wires and tension band wiring in a figure-8 pattern can be used for compression fixation. b. Lateral malleolar fracture: Screw fixation is applicable. For fibular fractures above the level of the distal tibiofibular syndesmosis or oblique fractures, plate or compression plate fixation may be used. c. Posterior malleolar fracture involving one-fourth or one-third of the lower tibial articular surface: Manual reduction is difficult and unstable. Open reduction with screw internal fixation is generally recommended. d. Dupuytren fracture: Transverse fixation of the distal tibiofibular joint with a bone bolt, along with repair of the deltoid ligament, may be employed.

Traumatic arthritis