Medial Malleolus Fracture

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The ankle is one of the most versatile joint complexes in the body. It is specifically built for weight bearing, mobility, adaptability, and stability. The foot and ankle allow us the ability to walk, stand, and serve as our connection to the ground. The ankle must be able to withstand the stress of body weight and also be able to adapt to and react quickly to changes in the environment and walking surface.

A fracture is a break, typically in a bone. If the broken bone punctures the skin, it is then called an ‘open’ or ‘compound’ fracture. Fractures often occur due to car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause the weakening of the bones. Overuse can also cause stress fractures, which are very small cracks in the bone.

When you fracture the inner bone of your ankle, it is called a medial malleolus fracture. The medial malleolus is a specific region of the tibia bone, which is the biggest of the two lower leg bones. You may feel this area as a bump on the inner side of your ankle joint. It bears a high percentage of the weight-bearing load, therefore, this is a very common fracture. Usually, medial malleolus fractures involve the articular surface of the ankle joint, which is where the bones meet in the joint.

The break may occur by itself, however, it typically accompanies injuries on the lateral side of the ankle or a fibula fracture of the smaller of the two lower leg bones.

A vast majority of ankle fractures are caused by rotational forces (you step incorrectly and twist your foot inward or outward, which may lead to a break).

Causes & Symptoms

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Generally, medial malleolus fractures are classified by the actual orientation of the fracture line. Therefore, the five fractures linked to the condition include:

 

Chip fractures

Chip fractures are the sign of ligament rupture on the inner side of the ankle. Rather than the force of the injury (causing a bone break), the ligaments pull off directly where they attach to the bone. The ligament can pull off a tiny piece of bone as the ligament is ruptured. This condition is also known as an avulsion fracture. They are often reported with simple ankle sprains. The presence of an avulsion fracture, however, may indicate a more serious injury. An avulsion fracture of the ankle may require a cast or walking boot. In rare cases, if the bone fragment and main bone are way too far apart to fuse naturally, surgical treatment may be needed in order to reunite them.

Comminuted fractures

Comminuted fractures of the medial malleolus are generally high-energy injuries that break the bone into several pieces. Comminuted medial malleolus fractures can be quite challenging to treat given the limited surface area by which a surgeon can reconstruct the bone fragments.

Oblique fractures

The oblique medial malleolar fracture generally occurs along with a rotational injury that begins on the lateral side of the ankle. It is associated with an oblique fibular fracture and commonly happens at the corner of the ankle joint.

Vertical fractures

Vertical fracture typically occurs when the force is oriented more in the leg bone. These fractures can extend into the weight-bearing portion of the ankle joint.

Transverse fractures

The transverse fracture occurs in the same direction as the ankle joint line and is generally a small bone fragment. While these fractures extend into the ankle joint, they do not extend into the weight-bearing portion. In most cases, surgery is sometimes required to stabilize a transverse fracture using cannulated screws. These are screws that are carefully inserted through the skin using a hollow, narrow tube called a cannula.

 

Certain symptoms associated with medial malleolus fractures are:

 

Pain

Pain is localized around the medial malleolus or inner side of the ankle joint. Pain may worsen on turning the ankle inwards or outwards with difficulty in standing or walking. Following an injury, pain and swelling of the area are the most common symptom of medial malleolus fracture. Symptoms similar to pain following the condition usually develop over a few days when the fracture is caused due to repeated stress that results in another injury known as a stress fracture.

Bruising

Bruising is a sign of the spread of blood under the skin. The twist and turn of the ankle joint results in soft tissue trauma as well as fracture of the medial malleolus. The soft tissue trauma causes bleeding under the skin. The bleeding follows a collection of blood known as hematoma under the skin, subcutaneous tissue, and muscles. Furthermore, the blood that is spread in the subcutaneous tissue may infiltrate into the dermis section of the skin and cause a purple discoloration of the skin that is affected.

Other symptoms linked to medial malleolus fractures include:

  • Stiffness in the ankle joint.
  • Limited/restricted range of motion
  • Rapid joint swelling and tenderness
  • Ambulation difficulty

Who gets Medial Malleolus Fracture?

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There are many risk factors that can be presented after an injury occurred in the medial malleolus, such as:

  • Osteoporosis – Osteoporosis is a disease that results in a decreased concentration of calcium. Overuse of the ankle joint or over-twist of the foot and ankle can cause a fracture of your medial malleolus.
  • Vehicle accident – Vehicle / motorbike accidents resulting in head-on collisions can cause an inward impact on the front end of the car. The left foot resting on the floor or right foot on the accelerator gets impacted and jammed which may result in a forceful rotation, hyper-flex, or hyper-extended ankle joint. Such joint movement may cause a fracture of the medial malleolus.
  • Occupation laborers – Some of the causes of a medial malleolus fracture are also related to a direct blow to the ankle joint or its inner side of the ankle joint while at work by moving objects or operating certain machinery.
  • Sports – Sports that involve repetitive twisting and turning of the lower leg and foot can easily cause injury of the ankle joint that may result in a medial malleolus fracture. Some of these sports activities include soccer, tennis, cross-country, and martial arts.

How does it affect you? How serious is it?

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If your medial malleolus has been severely fractured, and if surgery is performed, the ultimate concerns are infection and healing problems. The ankle joint is treated with caution after surgery because there is very little to protect the bone, with just a layer of skin covering the surgical repair. The other major concern with any ankle fracture injury is that while the bone generally tends to recover well, there may be cartilage damage inside the ankle joint from the injury itself. This cartilage damage can lead to early ankle arthritis.

Recommended Treatment & Rehabilitation

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During a diagnosis for a medial malleolus fracture, your doctor will begin by examining your ankle to check for points of tenderness. The precise location of your pain can help determine its cause. Next, your doctor may move your foot into different positions to observe and check your range of motion. You may also be asked to walk for a short distance so that your doctor can examine your gait.

If your signs and symptoms suggest a break or fracture, your doctor may suggest one or a combination of the following imaging tests below:

  • X-rays – Most ankle fractures can be easily visualized on X-rays. A technician may need to take X-rays from several different angles so that the bone images won’t overlap too much. Stress fractures often do not appear on X-rays until the break actually starts healing.
  • Bone scan – A bone scan can help your doctor diagnose fractures that do not appear on X-rays. He or she will inject a small amount of radioactive material into a vein. The radioactive material is then attracted to your bones, especially the parts of your bones that have been damaged. Damaged areas, including stress fractures, show up as bright spots on the resulting image.
  • Magnetic Resonance Imaging (MRI) – MRI uses radio waves and a strong magnetic field to create very detailed images of the ligaments that help hold your ankle together. This imaging helps to show ligaments and bones and can identify fractures not seen on X-rays.
  • Computed Tomography (CT) scans – CT takes X-rays from many different angles and combines them to make cross-sectional images of internal structures of your body. CT scans can reveal more detail about the injured bone and the soft tissues that surround it. A CT scan may help your doctor determine the most recommended treatment for your fractured medial malleolus.

A physiotherapist can help treat a medial malleolus fracture after it has been treated by a physician. After the bone is healed, a physiotherapist can help you regain your strength, motion, balance, and sports skills. After your leg is placed in a cast or a cast boot, your physiotherapist will teach you how to walk without bearing weight on the injured ankle, using crutches or a walker. Some of these physiotherapy treatments will include:

  • Reducing swelling – Swelling is commonly the first sign after an ankle fracture. Treatment may include gentle massage, the use of a compression wrap, ice, or heat, and elevating the affected ankle when at rest.
  • Walking instruction – Your physiotherapist will help you begin to put some of your weight on the injured leg, gradually progressing to full weight.
  • Gait training – Your physiotherapist will offer specific instruction and exercises to restore a normal walking pattern. The focus will be on how your foot and ankle move, and the timing of your steps.
  • Restoring your ankle mobility – Your physiotherapist may use manual therapy to gently move your foot and ankle joints and surrounding tissues to reduce stiffness and increase the ankle’s bending range of motion.
  • Returning to your regular activities – As you regain strength and flexibility, your physiotherapist will provide further training specific to your daily activities.

 

Your physiotherapist will design an exercise plan for you to begin after the cast has been removed to help you strengthen and regain motion in your fractured medial malleolus. The following exercises include:

 

Calf stretch

Sit with your affected leg straight and supported on the floor. Your other leg should be bent, with the foot flat on the floor. Next, place a towel around your affected foot just under the toes. Hold one end of the towel in each hand, with your hands above your knees. Pull back gently with the towel so that your foot stretches toward you. Hold the position for 15-30 seconds, then repeat 2-4 times a day.

 

Ankle dorsiflexion

Sit with your affected leg straight and supported on the floor. Your other leg should be bent, with the foot flat on the floor. Keeping your affected leg straight, gently flex your foot back toward your body so your toes point upward. Then slowly relax your foot to the starting position. Repeat this method 8-12 times a day.

 

Resisted ankle inversion

Sit on the floor with your good leg crossed over your other leg. Hold both ends of an exercise band and loop the band around the inside of your affected foot. Then press your good foot against the band. Keeping your legs crossed, slowly push your affected foot against the band so that the foot moves away from your good foot. Slowly relax, then repeat 8-12 times a day.

 

Resisted ankle eversion

Sit on the floor with your legs straight. Then, hold both ends of an exercise band and loop the band around the outside of your affected foot. Next, press your good foot against the band. Keeping your leg straight, slowly push your affected foot outward against the band and away from your good foot without letting your leg. Repeat this exercise 8-12 times a day.

Alternative & Homeopathic Treatment

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Many homeopathic treatments include the use of Epsom salt or simply resting your injured ankle. Some of these home remedies include:

  • Rest – It is recommended to not carry heavy items or play sports for a few days or weeks after you have dislocated your ankle in order to reduce further pain.
  • Eat healthy – Nutrients and vitamin D contained in meals can both help support your ankle recovery. You can also take vitamin D supplements as well.
  • Epsom salt – You can soak your ankle in a warm bath with Epsom salt after a few days of injury. Epsom salt may help soothe sore muscles and connective tissues, and it may help with joint stiffness.
  • Ice application – Apply ice to the ankle several times a day to help reduce pain and swelling. 
  • Compression – Apply an elastic compression bandage to help limit swelling.