Foot & Ankle Fractures

The foot and ankle have a total of 30 bones! That’s a lot of small bones that get wear and tear as we walk, climb and run for many hours each day. It’s no wonder that nearly everyone ends up with a stress fracture or some sort of break in the foot, ankle or toes. As we age, the bones can also weaken, causing them to become even more vulnerable.

Ankle
The ankle is made up of three bones — tibia (shin bone), fibula (small bone in the lower part of the leg) and talus (small bone that rests between the heel bone and tibia and fibula). The tibia and fibula are broken down into regions: 
Tibia — medial malleolus is the inside of the tibia; posterior malleolus is at the back of the tibia 
Fibula — lateral malleolus is at the end of the bone

When you break your ankle, your physician will refer to your break based on the region of the injury. You can also break the entire joint where the three bones meet or the joint in between the tibia and fibula.

Patients who have an ankle break normally experience immediate swelling, bruising and inability to put weight on the foot/ankle. Breaks occur from falling, car accidents, tripping or twisting the ankle.

How do you treat a broken ankle?
Treatment of a fracture is based on the severity, location, stability of the joint and whether ligaments are involved. If the fracture can be stabilized and x-rays do not indicate severe deformity or shattered bone fragment floating within the joint, then the orthopaedic surgeon may recommend splinting or casting the ankle for several weeks. X-rays will be taken after a few weeks to ensure that the bone is healing in place.

If the ankle is unstable, the bone is out of place and cannot be realigned or multiple bones are involved (along with ligament injury), your surgeon will most likely recommend a surgical repair. In these cases, the repair depends on the injury. During surgery, any broken bones will be realigned, fragments cleared from the joint and any damaged ligaments repaired. In most cases, the surgeon will use pins, screws or rods to hold the bone in place as it heals.

Recovering from a Broken Ankle Bone
Recovery from an ankle break is often lengthy and requires patience. At the very least, it takes bones six weeks to heal and if ligaments are involved, it takes months for a complete recovery. Patients with a simple break without surgery, will be able to return to normal activities in about three to four months. Patients who have undergone a surgical repair will have a longer recuperation.

Your orthopaedic surgeon will prescribe physical therapy in nearly all cases. It’s important that you learn how to use your ankle and keep it mobile. Strengthening muscles that surround the ankle will prevent future problems and provide support for the ankle joint. If you have had a splint or cast, your surgeon may recommend that you wear a brace for additional support when you participate in sports.

With any break, follow up x-rays and appointments with your orthopaedic surgeon are critical to long-term success. If the fracture is not healing properly, you can develop what is called a malunion where the bone has moved out of place and is not healing in position. This leads to uneven healing and can result in arthritis in the joint.

Foot & Toes
Your foot and toes can suffer from simple stress fracture to more serious breaks in the forefront of the foot and heel. Treatment depends on the severity and location of the fracture.

Forefoot Fractures 
The most common fracture on top of the foot is a stress fracture. Often, orthopaedic surgeons treat athletes — dancers, runners and gymnasts in particular — for these cracks in the foot since they are associated with high and frequent impact, but they anyone can have a stress fracture. All it takes is a soup can falling on your foot or a misstep going down stairs. Older adults who have osteopenia or osteoporosis are at greater risk for these types of fractures. For this reason, women are more likely to have a stress fracture.

The most common sites for stress fractures are the second and third bones (metatarsals) in the foot. You can also have stress fractures in the heel, fibula or navicular (bone in the mid part of your foot.)

What are the symptoms and treatment of a stress fracture?
Most patients report that symptoms come on gradually and are exacerbated when they are on their feet. Common symptoms include:

• Pain when walking, standing or running that worsens during the day, but is relieved with rest
• Swelling or tenderness on top of the foot or ankle and sometimes bruising

The first step in treating a stress fracture is to stop doing what is causing the pain. While you may at first have a simple stress fracture, repeated pressure and impact on the foot could result in a complete break in the bone. Your orthopaedic surgeon can examine and perform tests to confirm the diagnosis. Most stress fractures are treated conservatively and do not require surgery.

Over six to eight weeks, your surgeon will recommend that you rest the foot, apply ice packs to reduce swelling, take non-steroidal anti-inflammatory medications and wear a protective shoe or boot. One of the more common break sites is the fifth metatarsal bone — on the outside of the foot. This area takes longer to heal, so your surgeon may cast your foot to allow for complete healing. During this time, you will be on crutches. After a couple of months, you may be allowed to resume some exercises, but you may want to participate lower impact activities, such as swimming or biking.

In rare cases, surgery is required to repair a stress fracture. This involves inserting a pin, screw or plate to hold the small bones of the foot or bone in place to allow healing.

Broken Toes
In most cases, broken toes are a result of trauma or injury, such as dropping an object on your foot. Symptoms include pain, swelling, bruising, numbness and difficulty walking. If you drop a sharp object on your toe, you may break the skin and have bleeding and an open wound. It’s important to get treatment for your toe because any trauma to the joint that does not heal correctly can develop arthritis or deformity.

Your orthopaedic surgeon can determine the extent of the break by examining and x-raying your foot. Most toes will heal in six to eight weeks. During that time, your doctor will recommend that you elevate your foot, ice the site and stay off your foot as much as possible. Sometimes the doctor will do what is called buddy taping, where the injured toe is taped to an adjacent toe for added support as it heals. If x-rays show a compound or more complete break in the toe, you may have to have surgery to restore placement.

Heel Fractures
When you are involved in a front-end collision or fall from a height, you may break your heel (calcaneus) bone. This is a very painful and debilitating break that has a long recovery. Nearly all patients have to have surgery to ensure that is bone is heals properly.

What are the types of heel fractures occur and how are they treated? Heel fractures are classified based on the severity of the injury, which is directly related to the force of the break. The types of breaks include a stable fracture, which does not include displacement of the heel. Displaced fractures means that not only is the heel broken, but it is also out of alignment. In open fractures, the break is through the skin. Closed fractures do not break the skin, but the heel has sustained severe trauma. Comminuted fractures include three or more breaks within the heel, leaving the foot unstable.

All of these fractures cause pain, bruising, swelling and an inability to put weight on the foot. In order to repair the break — with a goal of restoring normal alignment of the heel bone — surgery is required. If your heel has not been displaced, your surgeon may cast your foot and allow it to heal for six to eight weeks. After that time, you will have additional x-rays to ensure proper placement of the heel. If at the time of the fracture, your heel is moved out of place, surgery is recommended. If the fracture is not open, your orthopaedic surgeon may advise to wait until some of the swelling has resolved. Immediate surgery is advised for all open fractures and in cases where the Achilles tendon has detached from the bone.

Two Types of Heel Fracture Surgery
Orthopaedic surgeons on staff at WakeMed perform two restorative procedures:

• Open reduction/internal fixation — Lose bone fragments are cleared from the area and the heel is placed back into its proper position with plates and screws.
• Percutaneous screw fixation — This minimally invasive procedure is performed through a series of small incision where large pieces of the heel are pushed back in place and screws are inserted to hold it together.

Recovery after surgery includes rest, pain medication to control your discomfort, staying off the foot for several months, along with physical therapy and exercises to improve range of motion. Once you are released to put some weight on the foot, you may need to use a cane or special boot at first. Heel breaks take a long time to fully mend. More complex fractures may take up to one years for a full recovery.