Fractures > Treatments
Open Reduction, Internal Fixation
Most severe ankle fractures are surgically stabilized
using plates and screws to ensure your broken bones
heal in the proper position. Severe ankle fractures
involve complete cracks in your bones and displacement
of the bones into improper positions. Fractures in the
base of your shinbone (tibia) and your smaller lower
leg bone (fibula) can be highly unstable, especially
when the bones shift position. Fractures that occur
with damage to one of the main ligaments providing support
for your ankle, called the deltoid ligament, typically
are considered unstable injuries and require surgery.
Your physician typically needs to make an open incision
and reconstruct the bones in your ankle to properly
treat a major ankle fracture.
Preparing for Surgery
Though you may not have much time between suffering
an ankle fracture and undergoing surgery, the actions
you take before surgery can be every bit as important
as the procedure itself in ensuring a healthy recovery.
to your return home from the hospital, make sure that
you have received any equipment you will need when you
get home. This may include crutches or household items
to make movement around the house easier. You should
receive prescriptions for any of these from your doctor
before you go home from the hospital.
physical problems or changes in your overall health,
such as a fever or infection, should be reported to
your surgeon, and you should notify your surgeon of
any new medications you are taking.
understand the potential risks and benefits of the surgery,
ask your surgeon any questions that will help you better
understand the procedure. It can also help to talk to
someone else who has undergone the same surgery.
a second opinion from another qualified surgeon is often
advisable, particularly in rare or unique cases.
check if the orthopedist performing the surgery is board-certified
or eligible, call the American Board of Orthopaedic
Surgery at 919-929-7103.
to ask the doctor
to take to the hospital
At most medical centers, you will
go to "patient admissions" to check in for
your operation. There may be separate check-in areas
for ambulatory outpatients (patients go home the same
day after surgery) and for overnight inpatient surgery,
so be sure to ask your doctor or an assistant about
this. After you have checked in to the hospital, you
will go to a holding area where the final preparations
are made. The mandatory paperwork is completed, and
your ankle area may be shaved, though this is not always
necessary. You will be asked to change into a hospital
gown and, if applicable, remove your watch, glasses,
dentures, and jewelry. You will have the opportunity
to speak with your orthopedic surgeon or an assistant
and meet the anesthesiologist or nurse anesthetist (a
nurse who has done graduate training to provide anesthesia
under the supervision of an anesthesiologist). An IV
(intravenous) line may be inserted into your arm at
this time. Then, you will walk or ride on a stretcher
to the operating room. Most patients are not sedated
until they go into the operating room. Here are some
important steps to remember for the day of your surgery:
will probably be told not to eat or drink anything after
midnight on the night before your surgery. This will
reduce the risk of vomiting while you are under general
for someone to drive you home when you are released.
a loose pair of shorts, sweatpants, or other clothing
that will fit comfortably over your short leg cast or
splint when you leave the hospital.
it easy. Keeping a good frame of mind can help ease
any nerves or anxiety about undergoing surgery. Distractions
such as reading, watching television, chatting with
visitors, or talking on the telephone can also help.
Open reduction and internal fixation
of your ankle fracture can take between two and three
hours to perform, depending on the different bones your
surgeon needs to fix in place with screws, pins, or
plates. Spinal anesthesia typically is given to numb
you from the waist down, and you usually are sedated
so you sleep through the procedure.
surgeon may have to make multiple incisions. Exposing
your small lower leg bone (fibula) usually requires
a straight lateral incision about ten to 12 centimeters
long made on the back and outside of your ankle. Usually
a smaller incision, about five to six centimeters, is
made on the inside part of your ankle to allow access
to the bony knob (medial malleolus).
bone most commonly fractured is the lower portion of
your fibula. Your surgeon typically fixes your broken
fibula with a plate and screws.
bony knob (medial malleolus) on the inside of your ankle
can be fractured as well. Screws or wires are used to
anchor the fractured portion to the rest of your shinbone.
fixation is used on any other areas that may be fractured
in your ankle.
the fractured bones broke the skin, the wound will be
washed out and some of the damaged tissue may need to
be cut away before your incisions are closed with stitches.
A splint is applied to immobilize your ankle, and you
are taken to the recovery room.
After surgery to stabilize your fractured ankle, you
will be transported to the recovery room where you will
be closely observed for one to two hours while the immediate
effects of anesthesia wear off. Your ankle will be immobilized
in a splint when you wake up, and your ankle will be
elevated. The post-surgery ankle splints usually are
made of a "U-shaped" plaster splint on the
inside and outside of your ankle that wraps around your
heel. It immobilizes your ankle, but it can be removed
more easily than a short leg cast. You will not be able
to see the two incisions wrapped in the splint, but
there usually is minimal bleeding after surgery. Surgical
repair of your anklebones can cause a substantial amount
of pain. Adequate pain medications will be prescribed
for you. You ordinarily are hooked up to an intravenous
(IV) patient-controlled analgesia (PCA) device, which
delivers pain medications in safe amounts when you push
a button. Some patients may be prescribed oral or intramuscular
pain medications. You usually can have visitors about
a half-hour after surgery if your physician feels you
are in a stable condition. Your temperature, blood pressure,
and heartbeat will be monitored by a nurse who, with
the help of the doctor, will determine when you are
ready to leave the recovery room and be transported
to the hospital ward for further post-operative care.
In some cases, you may be transported to a ward for
intensive care or heart monitoring if you have special
post-operative medical needs. Most patients spend one
to two days in the hospital before going home.
|Post-op in Hospital
After surgical repair of a fractured
ankle, most healthy patients remain in the hospital
from one to two days. However, some patients may require
a longer stay in the hospital due to pre-existing medical
problems or medical issues that may arise after surgery.
There are small risks of infection after major ankle
surgery, but there is not much you can do to prevent
infection because you cannot remove your splint. Your
physician should check your incision before you leave
the hospital and then again after 10 to 14 days so that
he can treat any rare incision problems. Each patient
is different and may have different criteria for being
able to go home. In general, the length of your hospital
stay is based on the amount of pain management you need.
You will receive fluids and medications, through an
intravenous (IV) line until you can drink an adequate
amount of fluids without nausea or vomiting. Most patients
can drink something the night after surgery and eat
something more substantial the following morning. Be
sure to ask for pain medications as soon as you feel
pain coming on, because medications are most effective
on pain that is building rather than on pain that is
already present. Your nurses will not give you more
than your doctor has prescribed and what is considered
to be safe. Physicians prescribe crutches to help you
move around without putting weight on your ankle. The
day after surgery, you typically meet a physical therapist
who teaches you about using crutches and helps you walk
around the hospital using them. You will likely be unable
to bear weight on your ankle for six to eight weeks
after surgery. Your physician may obtain X-rays of your
heel and ankle before you leave the hospital. You should
arrange for someone to drive you home when you are discharged.
For four to five days after surgery
to repair your fractured ankle, you should stay off
your feet, elevate your ankle above heart level, and
move around the house as little as possible. Crutches
usually are prescribed for about eight weeks so you
can keep your body weight off your ankle. Rest as much
as possible with your ankle elevated to help blood drain
away from your ankle and control swelling. The more
weight you put on your ankle, the greater your chances
of disrupting the healing process in your anklebones.
Household tasks that require you to be on your feet
may be difficult for eight weeks. It can be helpful
to have someone around the house to help with any physical
chores. You will be instructed to return to your physician’s
office for regular check-ups after surgery. The dressing
covering your wound inside your post-surgery ankle splint
usually does not need to be changed until the splint
is removed 10 to 14 days after surgery. A typical follow-up
schedule after you leave the hospital may go as follows:
to 14 days – Stitches are removed and your ankle
is put into a short leg cast.
weeks later – Return for a check-up. Possibly
receive X-rays and if necessary, a new cast. For the
next six to eight weeks, you may return for a check-up
every two weeks.
weeks after surgery – The cast is removed and
you receive a removable brace called a cam walker or
an air cast that can be worn inside your shoe. When
the cast comes off, you usually can start bearing weight
on your ankle, but you may continue using crutches or
a cane if your ankle hurts or feels weak. Your physician
or physical therapist teaches you the basic stretching
and range of motion exercises you can perform at home.
Depending on how well you are able to strengthen your
own ankle, your physician may prescribe physical therapy
to help you regain mobility.
to call the doctor after surgery
Eight weeks after surgery to repair your fractured
ankle, you usually are able to perform daily range-of-motion
exercises while wearing a cam walker or air cast. Ankle
stretching exercises should usually be done for
about four weeks prior to using weights to strengthen
your ankle. Depending on the extent of damage in your
ankle, you may lose some of the range of motion that
you had before the fracture. Your ankle may feel stiff
at first, but the pain should go away as you rebuild
your strength. Everyone heals at a different rate and
you should begin exercises slowly until your pain has
decreased. Your repaired bones of your ankle should
be stable before you put stress on your ankle with walking,
running, and other exercise. Physical therapy usually
involves learning an ankle stretching routine and performing
strengthening exercises. Once your bones have healed
and your strength is equal in both ankles, you may be
able to return to any sports and activities that you
participated in before the fracture. This can take from
four to six months after surgery. As you improve muscular
strength, the final phase is proprioceptive training,
in which you stand on balancing boards to assist training
your leg muscles to stabilize the foot and ankle.
Once your fractured ankle has healed, the bone should
be just as strong as it was before the fracture. To
prevent reinjury, you should strengthen the muscles
and tendons around your ankle. Appropriate strength
training, which focuses on the peroneal muscles of the
lower leg, and conditioning for the sports you play
are important preventive measures. Athletes should use
up-to-date equipment. To prevent ankle fractures, you
should try to play on good, level fields, courts, or
tracks. If your ankles are already weak, avoid playing
on uneven surfaces. Another preventive technique is
choosing the right footwear. Proper fit, support, and
design for specific sports should be taken into consideration.
Some shoes have built-in medial and lateral supports,
which may assist in preventing injury. Soccer shin-guards
with circular pads on the bony sides of the ankles may
prevent direct bruise or trauma to the bone. Hockey
players should wear extra ankle padding to help avoid
injury from sticks and skate blades. Adding calcium
supplements to the diet may help women with osteoporosis
strengthen their ankle bones. If your ankle starts to
hurt during exercise, you should return to your physician’s
office for a check-up.