Ankle Fracture (Broken Ankle)

First aid for a suspected broken ankle

1. Stop and do not walk on it.
2. Call 911 or your local emergency number if the bone is through the skin, the foot is deformed, or the foot is cold or numb.
3. Immobilize the ankle in the position you found it, using a pillow or rolled blanket as a splint. Do not try to straighten it.
4. Elevate the leg above the level of the heart.
5. Ice for 15 to 20 minutes, wrapped in a cloth, to reduce swelling.
6. Cover any wound with a clean dressing.
7. Do not eat or drink if surgery may be needed soon, for example with a deformity.

How the ankle is built

The ankle joint is formed where the lower ends of the shinbone (tibia) and the thin outer leg bone (fibula) wrap around the top of the talus, a foot bone. The bony bumps you can feel are the medial malleolus (inner, part of the tibia) and lateral malleolus (outer, part of the fibula). The back edge of the tibia is called the posterior malleolus. Strong ligaments hold these bones together, including the syndesmosis, which binds the tibia and fibula just above the joint.

Types of ankle fracture

Doctors also classify fibula fractures by their level relative to the syndesmosis (Weber A, B or C). The higher the fracture, the more likely the joint is unstable.

Symptoms

• immediate, throbbing ankle pain
• ankle swelling and bruising, which may spread to the foot and toes
• tenderness when pressing on the bone
• difficulty or inability to bear weight
• deformity in severe fractures
• a snap or crack heard at the time of injury (not always)

Broken ankle vs sprain

Sprains and fractures both cause pain, swelling and bruising after twisting the ankle, and can be hard to tell apart. Doctors use the Ottawa ankle rules to decide who needs an X-ray. An X-ray is needed if there is pain around the ankle bones and any of:

• tenderness along the back edge or tip of the outer ankle bone (lateral malleolus)
• tenderness along the back edge or tip of the inner ankle bone (medial malleolus)
• inability to take 4 steps both immediately after injury and when examined

For the foot, tenderness at the base of the fifth metatarsal (outer midfoot) or the navicular bone (inner midfoot) also calls for an X-ray.

See ankle sprain for ligament injuries.

Diagnosis

A doctor examines the ankle, foot, knee and leg, checks pulses and feeling in the foot, and orders X-rays from several angles. Stress or weight-bearing X-rays show whether the joint is stable. CT scans help plan surgery for complex fractures. MRI may be used to look for hidden fractures, cartilage or ligament injury. The whole length of the fibula is checked, because a high fibula fracture near the knee can accompany ankle injury.

Treatment

Non-surgical treatment

Stable fractures, where the bones are in good position and the joint is not shifting, are treated with:

• a walking boot or cast for about 6 weeks
• protected weight bearing as advised: some people can walk in the boot early, others use crutches at first
• elevation and ice to control swelling
• pain relief: acetaminophen (paracetamol), and short-term anti-inflammatories if your doctor agrees

Surgery

Unstable or displaced fractures are usually treated with open reduction and internal fixation (ORIF): the bones are realigned and held with plates and screws. Syndesmotic injuries may be fixed with screws or a flexible suture device. Severe swelling may need to settle for several days, with the leg splinted and elevated, before surgery.

After surgery, the ankle is protected in a splint or boot, and weight bearing is increased gradually over several weeks.

Recovery timeline

• 0 to 2 weeks: rest, elevation and pain control. Keep toes moving.
• 2 to 6 weeks: boot or cast. Weight bearing increases as advised.
• 6 to 12 weeks: the bone is usually healed enough to come out of the boot. Physical therapy restores movement, strength and balance.
• 3 to 6 months: most people return to normal walking and many sports. Swelling can persist for months.
• Up to a year: full recovery after complex fractures.

Smoking, diabetes and not following weight-bearing advice slow healing.

Complications

• blood clots (deep vein thrombosis) in the leg or lungs during reduced mobility
• stiffness and chronic swelling
• post-traumatic arthritis, especially after fractures involving the joint surface
• infection or wound problems after surgery
• the bone healing in a poor position or not healing (nonunion)
• irritation from hardware, which may need removal later
• compartment syndrome (rare)

Frequently asked questions

How do I know if my ankle is broken or sprained?

It can be hard to tell without an X-ray. A fracture is more likely if you cannot take 4 steps, there is tenderness directly on the ankle bones or the outer edge of the midfoot, or there is deformity. Get an X-ray if these apply. Sprain pain is usually in the soft area just below and in front of the ankle bone.

Can you walk on a broken ankle?

Sometimes, especially with small, stable fractures, but walking on it can make the injury worse. Avoid putting weight on a suspected fracture until it has been assessed. Your doctor will tell you when and how much you can walk in a boot or cast.

How long does a broken ankle take to heal?

The bone usually heals in 6 to 8 weeks. Getting back full movement, strength and balance with physical therapy takes longer: most people return to normal activities in 3 to 6 months, and complex fractures can take up to a year.

Does a broken ankle always need surgery?

No. Stable fractures, such as many breaks of the outer ankle bone, heal well in a boot or cast. Surgery is needed when the fracture is displaced, both sides of the ankle are broken, or the joint is unstable.

What helps a broken ankle heal faster?

Follow weight-bearing advice, keep the leg elevated early on, do not smoke, eat enough protein, calcium and vitamin D, keep diabetes controlled, and do your physical therapy exercises. Report increasing pain, calf swelling or wound problems promptly.