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{{AdultPage|ankle fracture (peds)}}
==Background==
==Background==
*Always palpate proximal leg to r/o [[Maisonneuve]]
[[File:Weber Classification - latin.png|thumb|Danis–Weber classification of ankle fractures (Types A, B and C).]]


==Malleolar Fractures==
==Clinical Features==
# Isolated Malleolar
*Examine for ecchymoses, abrasions, or swelling
## Stable if displaced <2mm, joint surface involvement <25%, and no contralateral or syndesmotic injury
*Vascular and neurologic assessment
# Medial Malleolus Fx
**DP and PT pulses
## Is it really isolated? (frequently associated with lateral or posterior injuries)
**4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
# Posterior Malleolus Fx
*Note skin integrity and areas of tenderness or crepitus over ankle
## Usually occurs in association w/ post. tibiofibular ligament injury / fibular fx
*Range joint passively and actively to evaluate for stability
## Rarely occurs in isolation!
*Examine joints above and below the ankle
# Bimalleolar
*Perform anterior drawer test (positive exam suggests torn ATFL)
##  Lateral + medial malleoli fx
*'''Always palpate entire length of fibula to rule-out [[Maisonneuve Fracture]] (fibulotibialis ligament tear)'''
## Unstable
**Perform a crossed-leg test to detect syndesmotic injury
# Trimalleolar
*Evaluate integrity of Achilles tendon ([[Achilles Tendon Rupture#Clinical Features|Thompson test]])
## Lateral + medial + posterior malleoli fx
*Palpate midfoot and base of 5th metatarsal for tenderness
## Requires surgical stabilization


==Diagnosis==
==Differential Diagnosis==
===Imaging===
{{Other ankle injuries DDX}}
#[[Ottowa Ankle Rules]]
# 3 views:
##AP - Best for isolated lateral and medial malleolar fractures
##Oblique (mortise) - Best for evaluating for unstable fracture or soft tissue injury
###At a point 1cm proximal to articular surface of tibia the space between the tib/fib should be ≤6cm
##Lateral - Best for posterior malleolar fractures


===Classification===
{{Distal leg fractures DDX}}
'''Danis-Weber system'''
*type A-fibular Fx at or below the joint line without syndesmotic involvement.
*type B-fib Fx at joint level with partial syndesmotic ligament injury.
*type C-fibular Fx above the joint level and complete syndesmotic disruption.
**C-diaphyseal (Dupuytren Fx) or proximal fibular Fx (maissoneuve).


'''Fracture Types'''
{{Foot and toe fractures DDX}}
#lateral malleolar-Tx depends on type A, B, or C
#A-splinting in ED, 6-8 weeks in cast.NWB for three weeks.
#B-often requires a surgical repair.
#C-surgery usually required.


==Management==
==Evaluation==
# Lateral malleolar Fx
[[File:Danis–Weber classification on X-ray.jpg|thumb|Danis–Weber classification on X-ray.]]
## Stable - >90% have good clinical result
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
### Treat like severe ankle sprain
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
## Unstable = displacement >2mm, medial fx, or medial ligament disruption
[[File:WeberBAPMedp.jpg|thumb|Weber B AP]]
### Medial tenderness indicates need for stress xrays to determine degree of instability
[[File:WeberCOBMedp.jpg|thumb|Weber C Oblique]]
#  Medial or posterior malleolar Fx
[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]
## Must confirm no other injuries!
## If non-displaced, isolated:
### Short-leg posterior splint (ankle at 90o)
### Non-weight bearing
### Refer in 5-7 days
# Lateral malleolar fx with deltoid injury OR bimalleolar OR trimalleolar fx
## Short-leg posterior splint (ankle at 90o)
## Refer within few days for surgical intervention


==Disposition==
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture)
# Emergent
*3 views:
## Open fracture
**AP: Best for isolated lateral and medial malleolar fractures
## Fx/dislocation with vascular compromise
**Oblique (mortise)
## Fx/dislocation with significant tenting of the skin
***Best for evaluating for unstable fracture or soft tissue injury
# Recommended (pt often admitted for repair)
***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
## Tillaux/triplane fractures
**Lateral: Best for posterior malleolar fractures
## Intrarticular fractures with displacement
*Consider proximal tib/fib films and talus fractures
## Pilon fractures (reduce if ortho unavailable)
## Trimalleolar fractures
## Maisonneuve Fx
## Any Fx with significant disruption of mortise
# Recommended (phone is ok)
## Bimalleolar Fx
# Minimally displaced medial or lateral malleolar Fx


==Complications==
===Classification (Danis-Weber System)===
# Nerve damage
[[File:WeberclassRadioped.jpg|thumb|]]
# Peroneal nerve (lateral ankle injury)
*System based on level of the fibular fracture and characterizes stability of fracture
# Weak foot dorsiflexion
*Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)
# Tibial nerve (medial ankle injury)  
 
# Compartment syndrome
====Type A====
# Nonunion or malunion
*Fibula fracture below ankle joint/distal to plafond
# Fracture blister/skin necrosis
**Medial malleolus often fractured
**Tibiofibular syndesmosis intact
**Usually stable: occasionally requires ORIF
 
====Type B====
*Fibula fracture at the level of the ankle joint/at the plafond
**Can extend superiorly and laterally up fibula
**Tibiofibular syndesmosis intact or only partially torn
**No widening of the distal tibiofibular articulation
**Medial malleolus may be fracture
**Possible instability
***Use gravity or weight bearing stress X-rays to determine stability <ref>Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1</ref>
 
====Type C====
*Fibula fracture above the level of the ankle joint/proximal to plafond
**Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
**Medial malleolus fracture
**Unstable: requires ORIF
 
==Management & Disposition==
{{General Fracture Management}}
 
===General Ankle Fracture===
*Determined by stability of fracture:
**Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
**Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint
 
===Isolated lateral malleolar fracture===
*If stable (see Weber classification) treat like severe [[Ankle Sprain]]
*Signs of instability:
**Displacement >3mm
**Associated medial malleolus fracture
**Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
**Widening of medial clear space (suggests deltoid ligament injury)  
 
===Isolated medial or posterior malleolar fracture===
*Must rule-out other injuries
*If non-displaced, isolated:
**[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)
**Non-weight bearing
**Refer to Ortho in 5-7d
 
===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture===
[[File:Bimalleolar fracture legend.jpg|thumb|Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.]]
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)
*Immediate reduction or ortho consult in ED


==See Also==
==See Also==
*[[Maisonneuve]]
*[[Ankle (Main)]]
*[[Pilon Fx]]
*[[Ottowa Ankle Rules]]
*[[Ankle Sprain]]
*[[Ankle Sprain]]
*[[Ankle Fracture (Peds)]]
*[[Ankle Fracture (Peds)]]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve Fracture]]
*[[Pilon Fracture]]
*[[Fracture (Main)]]
*[[Splinting]]
== Calculators ==
{{Ottawa_Ankle_Calculator}}
==External Links==
*http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
*Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378


[[Category:Ortho]]
==References==
<references/>
[[Category:Orthopedics]]

Revisión actual - 15:07 21 mar 2026

This page is for adult patients. For pediatric patients, see: ankle fracture (peds)

Background

Danis–Weber classification of ankle fractures (Types A, B and C).

Clinical Features

  • Examine for ecchymoses, abrasions, or swelling
  • Vascular and neurologic assessment
    • DP and PT pulses
    • 4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
  • Note skin integrity and areas of tenderness or crepitus over ankle
  • Range joint passively and actively to evaluate for stability
  • Examine joints above and below the ankle
  • Perform anterior drawer test (positive exam suggests torn ATFL)
  • Always palpate entire length of fibula to rule-out Maisonneuve Fracture (fibulotibialis ligament tear)
    • Perform a crossed-leg test to detect syndesmotic injury
  • Evaluate integrity of Achilles tendon (Thompson test)
  • Palpate midfoot and base of 5th metatarsal for tenderness

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

Danis–Weber classification on X-ray.
Weber A Oblique
Weber B Oblique
Weber B AP
Weber C Oblique
Weber C AP
  • Ottawa Ankle Rules (sen 96-99% for excluding fracture)
  • 3 views:
    • AP: Best for isolated lateral and medial malleolar fractures
    • Oblique (mortise)
      • Best for evaluating for unstable fracture or soft tissue injury
      • At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
    • Lateral: Best for posterior malleolar fractures
  • Consider proximal tib/fib films and talus fractures

Classification (Danis-Weber System)

WeberclassRadioped.jpg
  • System based on level of the fibular fracture and characterizes stability of fracture
  • Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)

Type A

  • Fibula fracture below ankle joint/distal to plafond
    • Medial malleolus often fractured
    • Tibiofibular syndesmosis intact
    • Usually stable: occasionally requires ORIF

Type B

  • Fibula fracture at the level of the ankle joint/at the plafond
    • Can extend superiorly and laterally up fibula
    • Tibiofibular syndesmosis intact or only partially torn
    • No widening of the distal tibiofibular articulation
    • Medial malleolus may be fracture
    • Possible instability
      • Use gravity or weight bearing stress X-rays to determine stability [1]

Type C

  • Fibula fracture above the level of the ankle joint/proximal to plafond
    • Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
    • Medial malleolus fracture
    • Unstable: requires ORIF

Management & Disposition

General Fracture Management

General Ankle Fracture

  • Determined by stability of fracture:
    • Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
    • Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint

Isolated lateral malleolar fracture

  • If stable (see Weber classification) treat like severe Ankle Sprain
  • Signs of instability:
    • Displacement >3mm
    • Associated medial malleolus fracture
    • Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
    • Widening of medial clear space (suggests deltoid ligament injury)

Isolated medial or posterior malleolar fracture

  • Must rule-out other injuries
  • If non-displaced, isolated:

Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture

Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.

See Also

Calculators

Ottawa Ankle Rules

Ottawa Ankle Rule
Criteria No (0) Yes (+1)
Ankle X-ray is required if there is pain in the malleolar zone AND any of the following:
  Bone tenderness along distal 6 cm of posterior edge of tibia or tip of medial malleolus 1
  Bone tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus 1
  Inability to bear weight both immediately and in the ED (4 steps) 1
Foot X-ray is required if there is pain in the midfoot zone AND any of the following:
  Bone tenderness at the base of the 5th metatarsal 1
  Bone tenderness at the navicular 1
  Inability to bear weight both immediately and in the ED (4 steps) 1
Positive Criteria / 6
Interpretation
Score = 0 No X-ray needed — Sensitivity 96.4–99.6% for clinically significant fractures.
Score ≥ 1 X-ray recommended — Ankle and/or foot x-ray indicated based on positive criteria location.
References
  • Stiell IG et al. A study to develop clinical decision rules for radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-390. PMID 1554175.
  • Stiell IG et al. Decision rules for radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269:1127-1132. PMID 8433468.

External Links

References

  1. ↑ Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1
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