Generality
The malleolus fracture is the skeletal injury marked by the rupture of one or both of the ankle malleoli.
There are at least three types of malleolus fractures: the unimalleolar fracture, the bimalleolar fracture and the trimalleolar type fracture.
The typical symptoms of a generic malleolus fracture consist of: pain, hematoma, swelling, skeletal deformity and lameness.
For a correct diagnosis of fracture of the malleolus and of the triggering causes, physical examination, anamnesis and X-rays are almost always sufficient.
Treatment depends on the severity of the fracture and the number of fractured malleolus. For mild fractures, the planned therapy is conservative, while, for more serious fractures, the planned treatment is surgical.
Short anatomical reference of the malleoli
Two for each lower limb, the malleoli (in the singular, malleolus ) are the bony prominences visible on the inner side and on the external side of each ankle. The ankle is the important articulation of the human body, located on the border between leg and foot.
The malleolus present on the inner side of the ankle belongs to the distal end of the tibia and, in the anatomical language, is called the tibial malleolus or medial malleolus . The malleolus present on the outer side of the ankle, on the other hand, is part of the distal end of the fibula (or fibula ) and, in the language of the anatomists, is called the peroneal malleolus or lateral malleolus .
Reminding readers that the tibia and fibula constitute the skeleton of the leg, the two malleoli - the tibial and the peroneal - cover the important task of providing stability to the ankle joint, particularly during very pronounced movements of the foot.
In anatomy, medial and lateral are two terms of opposite meaning, which serve to indicate the distance of an anatomical element from the sagittal plane . The sagittal plane is the anteroposterior division of the human body, from which two equal and symmetrical halves are derived.
Mediale means "near" or "closer" to the sagittal plane, while lateral means "far or" farther "from the sagittal plane.
What is the malleolus fracture?
The malleolus fracture is the skeletal injury which consists in the rupture of one or both visible bony prominences at the ankle level.
In other words, it is an ankle injury characterized by the rupture of one or both malleoli.
TYPES OF MALLEOL FRACTURES
Doctors distinguish malleolus fracture episodes in three main types: the type of unimalleolar fractures, the type of bimalleolar fractures and the type of trimalleolar fractures.
- Unimalleolar fracture : it is the bony rupture of only one of the two malleoli.
If the unimalleolar fracture affects the malleolus that lies on the inner side of the ankle (tibial malleolus), the doctors speak, more properly, of a tibial malleolus fracture (or fracture of the medial malleolus); if, on the other hand, the unimalleolar fracture relates to the malleolus that is on the external side of the ankle, the doctors preferably speak of a fracture of the peroneal malleolus (or fracture of the lateral malleolus).
- Bimalleolar fracture : also known as Pott's bimalleolar fracture, is the contemporary bone rupture of the tibial malleolus and peroneal ankle malleolus.
- Trimalleolar fracture : also known as Palle's trimalleolar fracture, it is a triple injury, characterized by the simultaneous bone rupture of the peroneal malleolus, the tibial malleolus and the posterior section of the distal end of the tibia (improperly called the posterior malleolus).
Generally, episodes of Palle's trimalleolar fracture also involve stretching or injury to the ankle ligaments .
Epidemiology
The malleolus fracture represents the most common ankle injury; it precedes, therefore, the episodes of fracture of the talus (main bone of the tarsus of the foot) and the lesions of the so-called ligaments of the ankle.
In 60 to 70% of clinical cases, the malleolus fracture is a unimalleolar fracture; in 15 - 20% of clinical cases, it is a bimalleolar fracture; finally, in 7 - 12% of clinical cases, it is a trimalleolar fracture.
In general, malleolus fracture events are equally distributed between men and women. However, it is good to bring back to the reader a curiosity: men with a malleolus fracture belong more frequently to the young adult population, while women with a malleolus fracture belong much more often to the population aged between 50 and 70 years.
Causes
The main causes of malleolus fracture include:
- Excessive twisting or rotating ankle movements. In general, those who practice sports, such as football, rugby, volleyball, American football, etc. are victims of such movements;
- Accidental falls or stumbling, which may occur, for example, during a walk, a particular work activity and a certain domestic activity;
- Strong impacts on the ankles or lower limbs in general, resulting from motor or motorcycle accidents.
Symptoms and Complications
The typical symptoms and signs of a fracture of the malleolus consist of: ankle pain, ankle swelling, ankle hematoma, skeletal deformity at the ankle level, difficulty walking (lameness) and reduced ankle mobility.
POSSIBLE PRESENTATIONS OF A MALLEOL FRACTURE
Based on the characteristics of the present bone lesion, a fracture of the malleolus can occur in various ways: for example, it may be composed or decomposed, stable or unstable, simple or multi-segmented, closed or open, etc.
- In compound fractures the fragments of the fractured bone retain their anatomical position; in displaced fractures, on the other hand, the fragments of the fractured bone are displaced with respect to their natural anatomical position (more serious injury).
- In unstable fractures we see the presence of deforming forces (such as muscle strength), which hinder the approach of the fragments of the fractured bone, drastically slowing down the healing process. In stable fractures, on the other hand, there are no deforming forces, so the fragments of the fractured bone are already in a position that favors the healing process.
Generally, a stable fracture is composed or slightly decomposed, while an unstable fracture is, almost always, decomposed.
- In simple fractures there is only one breaking point, from which two bone fragments result; in pluriframmentary (or comminuted) fractures, there are more fracture points, therefore definitely more than two bone fragments.
As a rule, simple fractures are also stable, while multifragmentary fractures tend to be unstable.
- In open fractures the peculiarity is the protrusion, from the skin, of a fragment of the fractured bone. In addition to creating a cutaneous wound at risk of infection, this protrusion can give rise to skeletal deformities of various degrees and more or less severe muscular injuries. In closed fractures, on the other hand, there is no protrusion from the skin of any bone fragment.
Usually, closed fractures are compound, stable and simple, while open fractures are displaced, unstable and pluriframmentary.
COMPLICATIONS
The most severe malleolus fractures are a factor favoring ankle osteoarthritis, especially if the treatment has been inadequate.
As stated, open malleolus fractures can instead be the cause of infections, skeletal deformities and / or muscle injuries .
Diagnosis
In general, the diagnostic procedure for patients with a suspected malleolus fracture includes: an accurate physical examination, a careful medical history and a series of diagnostic imaging tests.
Diagnostic imaging tests are essential to confirm any suspicion related to the presence of a bone fracture.
OBJECTIVE AND ANAMNESIS EXAMINATION
The physical examination is the set of diagnostic "maneuvers", performed by the doctor, to verify the presence or absence, in the patient, of the signs indicative of an abnormal condition.
In case of suspected fracture of the malleolus, the most classic of objective examinations has as its object the painful ankle and involves at least two diagnostic "maneuvers": the search for some hematoma, swelling, deformity, etc. and an assessment of the ability to move.
Moving on to the anamnesis, the latter is the critical collection and study of symptoms and facts of medical interest, reported by the patient or his family members (NB: family members are involved, above all, when the patient is small).
In case of suspected fracture of the malleolus, the most classic of the anamnesis is able to reveal the possible triggering factors and the conditions of risk.
DIAGNOSTICS FOR IMAGES
The ideal diagnostic imaging tests for detecting a malleolus fracture are:
- X-rays : it is a practical exam, which clearly shows, on a photographic plate or a digital image, the characteristics of a bone fracture. For example, thanks to X-rays, doctors can understand if a malleolus fracture is composed, broken down, open, etc.
Although painless, it is to be considered minimally invasive, as its execution involves exposing the patient to a small dose of ionizing radiation harmful to humans.
- TAC (or Computerized Axial Tomography ): is a test that provides three-dimensional images of internal organs, including bones. The images are very clear and have details that X-rays cannot grasp.
For example, unlike X-rays, a CT scan is able to detect possible involvement of ankle ligaments.
The doctors use the TAC only if strictly necessary, as the exam in question, although completely painless, involves exposing the patient to a non-negligible dose of ionizing radiation harmful to humans.
- Nuclear magnetic resonance (or MRI ): thanks to the creation of magnetic fields, an MRI provides detailed images of soft tissues (ligaments, etc.) and hard tissues (bones), located in the anatomical region under investigation. Completely painless, it is also a completely non-invasive test, as the magnetic fields, which are used to create images, are not at all harmful to human health.
Treatment
The treatment of a malleolus fracture depends on which and how many malleoli are fractured and on the severity of the fracture.
In general, the rule is valid that, if the fragments of the malleolus are close to each other and the injury is not serious, rest and immobilization of the affected ankle are sufficient for at least 6-8 weeks; while, if the fragments of the malleolus are distant or obstructed in the approach and the injury is serious, the use of surgery is fundamental.
THERAPY IN THE EVENT OF A PERONEAL MALLEOL FRACTURE
A non-serious fracture of the peroneal malleolus (therefore a compound and stable fracture) involves a conservative treatment, consisting of a period of rest, immobilization of the ankle by plastering and the use of crutches to avoid resting on the ground. Generally, in these circumstances, plastering affects the foot and most of the leg and lasts about 6 weeks.
A severe fracture of the peroneal malleolus, on the other hand, requires the intervention of the surgeon, who must first reposition the bone fragments in their correct anatomical position and then weld them together using screws, pins, etc. At the end of the surgery, rest, the immobilization of the operated ankle and the use of crutches, to avoid resting on the ground, are a must. Usually, rest and immobilization should last between 6 and 8 weeks.
THERAPY IN THE CASE OF A TIBIAL MALLEOLIS FRACTURE
The treatment envisaged in the presence of a tibial malleolus fracture is very similar to that described above, in the case of a peroneal malleolus fracture.
THERAPY IN THE CASE OF A BIMALLEOLAR FRACTURE
Regardless of their severity, episodes of bimalleolar fracture require surgery, followed by: a rest period, ankle immobilization for at least 6 weeks and the use of crutches.
The only cases of bimalleolar fractures, for which surgery is not recommended, are those in which the patient suffers from serious health problems. In such situations, in fact, surgical practice could be fatal.
THERAPY IN THE EVENT OF A TRIMALLEOLAR FRACTURE
The therapy envisaged in the presence of a trimalleolar fracture is very similar, if not equal to that described above, in the case of a bimalleolar fracture; also the category of patients unsuitable for surgery is the same.
HOW TO UNDERSTAND IF YOU HAVE HAD THE HEALING?
Whether in the presence of severe fractures, or in the presence of non-serious fractures, the only way to ascertain the welding of a fractured malleolus is to observe its state of health, by means of an X-ray examination.
If, based on the X-ray examination, some bone lesion persists, the attending physician is forced to immobilize the ankle and part of the leg again, and to recommend more rest.
PHYSIOTHERAPY: A FUNDAMENTAL STEP
Any fracture of the malleolus requires, after the period of rest and immobilization of the ankle, a cycle of physiotherapy sessions.
In such circumstances, physiotherapy serves to re-establish the joint mobility of the affected ankle, strengthen the muscles of the immobilized lower limb for a long time, etc.
Prognosis
The prognosis of a properly treated malleolus fracture depends on the severity of the fracture. This means that less severe fractures have a better prognosis than more serious fractures.
Prevention
In sports, the risk of malleolus fracture can be reduced with periodic stretching of the leg muscles and their reinforcement, with specific training sessions.
Those who have suffered a malleolus fracture in the past can reduce the risk of a relapse by wearing an ankle brace.
