Anklen Fracture Classification, Complications ,Physiotherapy management

 Fractures around the ankle Classification 

◼ Malleolar fractures or adduction–abduction fractures 

◼ Hind foot fractures – fracture of the calcaneum and talus 

◼ Midfoot fractures – fracture of the navicular, three cuneiform bones and cuboids 

◼ Forefoot fractures: 

◼ Fracture of the proximal phalanx of the great toe 

◼ Fracture of the phalanges of the 2nd to 5th toes 

◼ Fractures of the 1st to 4th metatarsals 

◼ Fractures of the 2nd to 5th metatarsals 

◼ Fracture of the base of the 5th metatarsal C joints fracture 

◼ Metatarsal inversion injury – on a plantar flexed ankle 

Malleolar fractures (or adduction–abduction fractures) Fractures around the ankle are produced by forced adduction or forced abduction of the foot, often associated with an element of rotation or vertical compression. Forced abduction produces rupture of the medial ligament of the ankle, fracture of the medial malleolus or fracture of both malleoli 

Forced adduction produces rupture of the lateral ligament, fracture of the lateral malleolus or fracture of both the malleoli

Abduction injury. (A) Fibular fracture at the syndesmosis, and (B) as seen on radiograph. Note the horizontal fracture line in the medial malleolus.

When both malleoli are fractured, it is also called Pott’s fracture.

Treatment

 The main objective of the treatment is to restore the alignment of ankle mortice by accurate reduction of the fractures. The treatment can be conservative or operative.

Conservative 

treatment The fracture is manipulated under general anaesthesia and immobilized in a below-knee plaster cast for 6–8 weeks. The ankle may be mobilized after 8 weeks; however, weight bearing is allowed only after about 12 weeks.

Operative treatment 

Open reduction internal fixation is indicated where closed reduction has failed or the fracture gets redisplaced in the plaster or the fracture is grossly displaced. The fractures of medial and lateral malleoli are fixed internally by a screw or tension band wiring. The fracture in the fibula can also be fixed by a plate

(A) Fracture of the medial malleolus fixed by tension band wiring. (B) Fracture of the medial malleolus fixed by malleolar screws while the fracture of the lateral malleolus is fixed by plating. 

Complications 

1. Malunion: It leads to distortion of the ankle mortice and deformity. In later years, osteoarthritis may set in. 

2. Nonunion: It is common with fracture of the medial malleolus. Internal fixation by a screw or tension band wiring with bone grafting is the treatment. 

3. Joint stifness: It results following prolonged immobilization and oedema. It can be prevented by accurate reduction of the fracture and adequate physiotherapy as early as permissible. 

Physiotherapeutic management Objectives 

◼ To restore the maximum passive range of movements of the ankle, subtalar, metatarsophalangeal (MTP) and interphalangeal (IP) joints . 

◼ Acceptable form has to be associated with increased strength and endurance of the muscle groups acting over the ankle, subtalar, MTP and IP joints. 

◼ Steadiness and stability in standing, performing functions and while doing ambulatory activities without limp. 

◼ Concentrated exercise training session for the intrinsic muscles.

Expected problems 

◼ Lingering heel pain on weight bearing results in a permanent limping gait. 

◼ Later on, subtler joint osteoarthritis changes are observed. 

◼ Flattening of the foot area and weight-bearing pain results in uneven stepping and a limp.

 Physiotherapy management 

Fractures treated with a short leg brace 

◼ Check the cast to ensure full ROM at the knee and MTP joints. 

◼ Begin early active movements to the toes. 

◼ Keep leg elevated to prevent oedema. 8–12 weeks after removal of the cast 

◼ Active relaxed free rhythmic movements are guided to be performed in warm water. 

◼ Self-assisted passive, active, resistive and most importantly selfpassive stretch-hold to improve ankle dorsi- and plantarflexion are concentrated to get maximum ROM in these two movements. 

Weight bearing 

◼ Graduated weight bearing is initiated in parallel bars, walking aids or crutches to eliminate limp to the maximum with cast. 

◼ Full weight bearing after 12 weeks.

Fractures treated by conservative management 

During immobilization 

◼ Limb elevation 

◼ Strong repeated movements for the toes, knee and the hip. 

◼ Diapulse may be applied over the POP cast. 

◼ Non–weight-bearing crutch walking can be initiated on the second or third day. 

During mobilization 

1. Early passive mobilization: Early initiation of relaxed passive range of motion exercises is important. The patient should be made well conversant to practise them often. This can be done best by the patient sitting in a chair with the back supported. The distal portion of the affected leg rests just over the knee on the sound thigh. The ankle and foot, which are free to move, are grasped by the patient using both hands. Full range relaxed passive movements of the ankle and foot can be improved effectively  with repetitive efforts with the use of HP or warm water immersions. 

Relaxed passive movement in the maximum possible range, especially circumduction, causing minor discomfort but not pain are ideal to begin with (Cyriax, 1978). The passive movement should not be so forcible as to overstretch the fibrils that are gaining longitudinal attachment within the healing breach; nor should they be so gentle as to fail to disengage those fibrils that are gaining abnormal transverse adherence. Deep friction massage is also useful in preventing adhesions.

2. Thermotherapy: If there is no oedema, thermotherapy is advisable. It increases capillary permeability, promoting the reabsorption of extravasated fluid and dissolution of organized haematoma, helping early healing (Griffin and Karseli, 1978). 

3. Early muscle strengthening: Exercises to strengthen all the muscles should also be started as early as possible. The technique may be the same as described for early mobilization, except that the movements are active in this exercise. It can be made self-resistive also, if there is no pain. The movements should be taken to the maximum range, with isometric holding at the end of the range. As the exercises are selfresistive, the degree of resistance can be controlled to the level of pain and discomfort. 

While strengthening the muscles the patient should be told to concentrate more on the muscles of the anterior and lateral compartments of the leg which are usually weaker as compared to those of the posterior compartment. 

Exercising the toe flexors and intrinsic muscles should not be neglected, to maintain the tone and strength of the foot arches. In fact, active slow circumduction with toes tightly clenched is a simple and more effective exercise. 

4. Stretching exercises : It is important to stretch the posterior calf muscles. This needs prolonged gradual relaxation of the calf. It can be done by keeping the forefoot on a block or a book and pushing the heel down with the knee straight in standing, or with the knee bent to 90 degrees in sitting; putting a downward pressure over the knee with a block or a book placed under the forefoot. In standing, the body weight presses the heel down and stretches the gastrosoleus. 

5. Re-education in weight bearing: Proper placement of the injured limb, gradual weight bearing and the normal pattern of gait are to be progressed in stages. Weight bearing is started after 12 weeks

6. Speedy movements: Gradual initiation and progress to more vigorous exercises like toe walking, heel walking, spot jogging and single leg hopping

Fractures treated by open reduction and internal fixation 

The period of cast immobilization after surgery is usually less, about 3–4 weeks. Therefore, mobilization can be started early. Gentle relaxed passive movements as well as self-assisted procedures followed by thermotherapy should be started. The rest of the physiotherapeutic regime is the same as described for the conservative approach. However, SWD or US is contraindicated due to the metallic implants used for internal fixation