Lateral Malleolus Fracture
(Also known as a Fractured Fibula, Fractured Lateral Malleolus, Ankle Fracture, Broken Fibula)
What is a lateral malleolus fracture?
A lateral malleolus fracture is a relatively common condition characterized by a break in the bony prominence situated at the outer aspect of the ankle known as the lateral malleolus (figure 1).
Figure 1 – Lateral Malleolus Fracture Anatomy
The lower leg comprises of 2 long bones, known as the fibula and the tibia, which are situated beside each other (figure 2). The fibula bone lies on the outer aspect of the lower leg and forms joints with the tibia (near the knee and ankle) and the talus in the ankle (figure 2). The fibula bone has a bony lump situated at the outer aspect of the ankle known as the lateral malleolus (figure 1).
Figure 2 – Tibia, Fibula and Talus Anatomy
During certain activities such as landing from a jump, a forceful impact to the outer aspect of the ankle or when rolling an ankle, stress is placed on the fibula and lateral malleolus. When this stress is traumatic and beyond what the bone can withstand a break in the lateral malleolus may occur. This condition is known as a lateral malleolus fracture.
A lateral malleolus fracture is relatively common among the elderly, but can also occur in the younger patient. Often a fracture of the lateral malleolus occurs in combination with a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma).
Lateral malleolus fractures can vary in location, severity and type including avulsion fracture, stress fracture, Potts’ fracture, displaced fracture, un-displaced fracture, greenstick, comminuted etc.
Causes of a lateral malleolus fracture
A lateral malleolus fracture commonly occurs in association with a rolled ankle particularly with significant weight bearing forces. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the outer ankle. Lateral malleolus fractures are common in running and jumping sports involving change of direction such as football, soccer, rugby, basketball and netball.
Signs and symptoms of a lateral malleolus fracture
Patients with this condition typically experience a sudden onset of sharp, intense outer ankle or lower leg pain at the time of injury. This often causes the patient to limp or be unable to weight bear so as to protect the ankle. Pain can occasionally settle quickly leaving patients with an ache at the site of injury that may be particularly prominent at night or first thing in the morning.
Patients with a lateral malleolus fracture may also experience swelling, bruising and pain on firmly touching the affected region of bone. Pain may also increase during certain movements of the foot or ankle or when standing or walking (particularly up hills or on uneven surfaces) or when attempting to stand or walk. In severe lateral malleolus fractures (with bony displacement), an obvious deformity may be noticeable. Occasionally patients may also experience pins and needles or numbness in the ankle or foot.
Diagnosis of a lateral malleolus fracture
A thorough subjective and objective examination from a physiotherapist is essential to assist with diagnosis of a lateral malleolus fracture. An X-ray is usually required to confirm diagnosis and assess the severity of the fracture. Further investigations such as an MRI, CT scan or bone scan may be required, in some cases, to assist with diagnosis and assess the severity of the injury.
Treatment for a lateral malleolus fracture
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Prognosis of a lateral malleolus fracture
Patients with a fractured lateral malleolus usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in weeks to months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 weeks as guided by the treating physiotherapist.
Physiotherapy for a lateral malleolus fracture
Physiotherapy treatment is vital in all patients with this condition to hasten healing and ensure an optimal outcome. Treatment may comprise:
- soft tissue massage
- joint mobilization
- electrotherapy (e.g. ultrasound)
- ice or heat treatment
- ankle taping or ankle bracing
- the use of a protective boot
- the use of crutches
- exercises to improve strength, flexibility and balance
- activity modification
- a graduated return to activity plan
- footwear advice
Other intervention for a lateral malleolus fracture
Despite appropriate physiotherapy management, some patients with this condition do not improve adequately and may require other intervention. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization, review with a podiatrist for possible orthotics or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the fractured lateral malleolus. Occasionally, patients may require surgery to stabilize the fracture and a bone graft to aid fracture healing.
Exercises for a lateral malleolus fracture
The following exercises are commonly prescribed to patients with a lateral malleolus fracture following confirmation that the fracture has healed or that pain free mobilization can commence as directed by the surgeon. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate, advanced and other exercises. As a general rule, addition of exercises or progression to more advanced exercises should take place provided there is no increase in symptoms.
Foot and Ankle Up and Down
Move your foot and ankle up and down as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 3). Repeat 10 – 20 times provided there is no increase in symptoms.
Figure 3 – Foot and Ankle Up and Down (left leg)
Foot and Ankle In and Out
Move your foot and ankle in and out as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 4). Repeat 10 – 20 times provided there is no increase in symptoms.
Figure 4 – Foot and Ankle In and Out (right leg)
Foot and Ankle Circles
Move your foot and ankle in a circle as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 5). Repeat 10 times in each direction provided there is no increase in symptoms.
Figure 5 – Foot and Ankle Circles
Rehabilitation Protocol for a Lateral Malleolus Fracture
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Physiotherapy products for a lateral malleolus fracture
Some of the most commonly recommended products by physiotherapist to hasten healing and speed recovery in patients with this condition include:
- Protective Boots
- Ankle Braces
- Ankle Supports
- Ice and Heat Packs
- Wobble Boards (for rehabilitation)
- Dura Discs (for rehabilitation)
- Resistance Band (for strengthening)
- Sports Tape (for protective taping)
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- Ankle Stretches.
- Ankle Strengthening Exercises.
- Leg Stretches.
- Leg Strengthening Exercises.
- Balance Exercises
- How to use Crutches
- Ice or Heat
- R.I.C.E. Regime.
- Choosing a Shoe.
- Do I Need Orthotics?
- Return to Running Program.
- Return to Sport.
- Ankle Taping.
- Ankle Diagnosis Guide.
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A lateral malleolus fracture is an injury involving a complete break in the boney prominence located at the outer aspect of the ankle (i.e. the lateral malleolus). This usually occurs in association with a traumatic force (such as a rolled ankle or a direct blow) and causes a sudden onset of intense pain in the area. Accurate diagnosis (usually with X-Rays) followed by appropriate fracture management and then a comprehensive physiotherapy rehabilitation program is essential to optimise recovery.
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