Have You Suffered an Ankle Fracture?
Not all orthopaedic surgeons will be able to offer you up to date surgical techniques for ankle fractures. Many orthopaedic surgeons do not even treat ankle fractures (or any traumatic injury) as part of their day to day NHS practice.
The traditional way of managing ankle fractures involves using a plaster cast and a period of non-weight bearing for six weeks or more. However, there have been developments in the treatment of ankle fractures that allow better fixation, and immediate weight bearing, using removeable plastic boots rather than plaster casts.
The advantages of this more modern treatment are
immediate weight bearing – crutches are only for balance
biomechanically stronger ankle fixation
earlier return of joint movement
decreased risks of DVT
ability to wash the leg throughout treatment and recovery
ability to exercise the ankle
Not all orthopaedic surgeons are the same, and only some specialise in dealing with dealing with foot and ankle problems.
When you have suffered an ankle fracture, it is best to see an orthopaedic surgeon who specialises in problems involving the foot and ankle, so that you can have the most modern treatments.
Only a very small percentage of my patients will be asked to remain non-weight bearing after surgery. This is for patients who have ligament injuries to the joint between the tibia and fibula, or who are diabetic. Due to the techniques used in surgery, the vast majority of patients can be allowed to put their weight safely on their broken ankle immediately following surgery, using the support of a removeable boot.
Do you need surgery at all?
We now know that some ankle fractures are stable, and do not require surgery. These can be identified by the type of injury on an xray coupled with examination of your ankle. They may need support with a removeable plastic boot. This will allow weight bearing, although it may not be pain free as there is still a broken bone. After a week, a further xray is taken while standing to ensure that no displacement has occurred. If none has, then no further xrays are necessary and a period of six weeks supported weight bearing with the plastic boot is all that is required.
If the ankle is not stable, or it displaces after weight bearing, then surgery is required.
The surgery aims to fix all the bony components of the fracture to restore stability and allow weight bearing. More modern surgical approaches allow fixation of the back of the ankle joint, which restores stability. If this component is not fixed, then there is a higher risk of displacement and instability of joints.
Surgery is performed through incisions behind the fibula bone and also at the inner side of the ankle joint if the bone is broken here as well.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, displacement of the fracture, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation. After surgery, you may be prescribed blood thinning injections to decrease the risk of DVT, but weight bearing and exercises also decrease the risk of blood clots by keeping the blood flowing in the leg.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
You will have a plastic boot applied at the end of your operation. You will also have an injection behind the knee to numb the leg for 24 hours after surgery. You should not remove the boot for 36 hours. You should take painkillers regularly, whether or not you are in pain. At some point the injection behind the knee will wear off, and you will feel pain.
The plastic boot can be removed after 36 hours, and you can start to perform exercises to keep the joints supple. I recommend drawing the alphabet with your toes as this moves all the joints in the foot. The boot is applied for all walking, but it does not need to be worn at night after the first two days.
After two weeks, the dressings are removed. The wound should be healed by now, and the leg can be soaked in the bath, or you can shower.
No further dressings are required, but the boot is worn for a further four weeks. At six weeks, if all is well, you can start to wean yourself off the boot.
Returning to Work
Although you may be walking with the boot confidently, it will take time to wean yourself off the boot again. Also, you should avoid excessive weight bearing as this will lead to further swelling of the ankle.
The type of work that you are returning to will play a part in deciding when you can return. If you work in an office, you may be able to return to work while you are still wearing the boot, provided that you can get to work. If your job involves manual work, you should not return to work until you are able to walk confidently without the boot, unless light duties can be found for you.
I would not recommend returning to driving before eight weeks following surgery, as you will not have the strength and endurance to press the pedals repeatedly, unless your injury is to the left ankle and you have an automatic car. At eight weeks, you should have a dry run in the vehicle – without turning on the engine. If you can press the pedals without pain or discomfort, then inform your insurance company that you wish to return to driving. Only after this should you drive, and if you find it painful, then wait another two weeks before trying again.