Some bones in the body can heal fairly easily if they break, but when it comes to the ankle, things are a little more complicated. The ankle joint is complex for several reasons and this makes treatment rather more difficult than a simple single bone.

Nevertheless, modern treatment for a broken ankle is remarkably effective, and following a period of rehabilitation it’s possible to return to full functionality.

Here’s an overview of a broken ankle, the treatment options and the rehabilitation.

The priorities

The need for broken bones to be held rigidly in the correct position is not a new concept say The Health Experts, indeed the plaster cast was first invented in the mid-19th century. For broken ankles, being held in the correct position is a critical priority.

The ankle has three main bones so there are many variables for a break. There may even be multiple fractures, depending on the type of trauma. The complex arrangement of the bones together with the fact the ankle is a hinge, weight-bearing joint mean that it’s absolutely vital to be held in the correct position.

As a weight-bearing joint, if the ankle heals in the wrong position, not only will it cause chronic pain and discomfort, it will also lead to difficulties with movement. This may mean a permanent limp or lack of a full range of movement, rendering sports or even walking normally impossible. In the longer term, arthritis may develop.

In terms of understanding, not much has changed in more than a century with reference to this need for immobility. However, the way in which it’s approached has altered significantly in recent decades.

The use of traction and bedrest

In the early to mid-20th century, it was common to use traction to make sure the bones of the ankle were held in position. Although extremely limiting to the individual, it eased some of the pain and ensured there was no risk of any of the bones shifting out of position. The length of time in traction varied depending on the orthopaedic surgeon treating the patient.

In modern orthopaedic surgery, traction is only rarely used and more commonly for complex fractures which are difficult to treat, such as the femur.

A lot more is understood about the complications of bedrest too. For the majority of types of broken ankle, it’s essential that no weight bearing activity is carried out for a minimum of six weeks, sometimes longer. Attempting to weight bear before this can move bones out of position and jeopardise healing.

Scientists now understand the detrimental effect that total bedrest can have on the whole body, including the muscles and the bones.

Research has shown that bone is not a fixed substance but instead, something that is constantly being replaced. This is primarily due to the role of osteoblasts but they require weight bearing activity in order to function. When there is no weight bearing movement, the loss of old bone continues but without new bone to replace it. This leads to a decrease in mineral bone density at a rate which can be 50 times higher than expected ageing.

The impact on soft tissues is possibly even greater than on bone, with everything from muscles to tendons, ligaments and other types of connective tissue all affected. Research in the 1980s revealed that once the function of ligaments reduces to 61% below normal, it will take in excess of one year to be restored, even with active and regular rehabilitation.

Muscle strength is also lost during bedrest; a study in 2008 showed this to be at the rate of approximately 12% per week. Conversely, active rehabilitation was only able to restore muscle strength at the rate of 6%. This means that the time it takes to restore muscles will be double the time they remain inactive. This doesn’t take into account any additional factors such as ligament and tendon degradation.

Treatment and rehabilitation

Much of the above knowledge about the effect of bedrest and total inactivity has only arisen in the last 15 years and treatment has been adjusted accordingly, while still maintaining the principles of holding the broken bones in position.

The challenge has been providing as much movement as possible to the rest of the body while still restricting weight-bearing activity on the broken ankle.

Splinting before placing the ankle in a cast is the most common treatment. Occasionally a complex fracture may require surgery and pinning, but that’s often not the case.

One of the biggest developments in recent years has been the evolution of the type of case used. Heavy plaster casts which were around 50 years ago have been replaced with lightweight fibreglass. This makes mobility easier, thereby reducing the deterioration of muscle and tissue function, while still protecting the broken bone.

Physiotherapy will be a large part of the rehabilitation and will be a prolonged process. For some broken ankles, full mobility could take up to two years to return. Even once you are allowed to weight-bear, you will have restrictions as you gradually regain strength and range of movement. Modern physiotherapy will sometimes use technology such as electronic stimulation to help muscles which are weak and struggling to recover. This works alongside more traditional rehabilitation techniques to gradually restore full weight-bearing activity.

A complex and slow process

Much of the treatment and rehabilitation is based on scientific knowledge which was gained some time ago. However, although some of the core principles have remained the same, much has changed with the improved knowledge about the holistic effect of treatments such as bed-rest. With physiotherapy able to rely on technology such as CT scanning which wasn’t around 50 years ago, modern success rates for full recovery are far superior.

We often imagine a broken bone as an injury that only occurs after a relatively severe accident so it can be surprising to discover that some bones can be fractured very easily.

This is certainly the case with the wrist; many broken wrists are sustained from simply tripping over and putting your hands out to protect yourself. There are some small bones within the wrist and it’s not difficult to break them, causing pain and swelling.

In the past you may have seen individuals with big, heavy casts on their arms deliberately designed to prevent the bones from moving but is that how broken wrists are treated? Here’s a closer look at how broken wrists are treated now, and how this differs from a few decades ago.

Historical Treatment

Once more was understood about the physiology of broken bones, it became very clear to doctors that keeping everything still while healing took place was a real priority. This has been known for a couple of centuries but historically doctors lacked the technology to be able to achieve this.

In the 18th and 19th centuries, amputations for broken bones were commonplace because the bone couldn’t easily be set and the limb would become weak and useless, or worse, infected. This was particularly the case with joints such as the wrist where amputation was relatively simple and the bones involved were small and easily fractured.

By the 1950s, knowledge and treatments were evolving fast and two doctors were at the forefront of pioneering changes. Dr Robert Danis and Dr Maurice Müller were at the forefront of the new treatments which sought to improve on some of the barbaric methods which were still being used for broken limbs.

It would be fair to say that these two medical practitioners were the inspiration for modern methods of nailing and plating, and were responsible for starting the shift towards more modern treatments.

However, back in the 1950s and for many of the following decades, huge emphasis was placed upon not moving the broken joint. This often meant a heavy cast was required and the joint was kept completely still.

This had the desired effect on the broken wrist, but recovery was often more complex and could take some time. This wasn’t entirely due to the bone, but rather the soft tissue which had been left completely immobile. Some individuals never fully recovered their full strength in the affected arm, due to the loss of tone in the soft tissue, rather than the fracture itself.

Some broken wrists needed to be pinned together, or held with plates and screws. Historically, stainless steel was used for any inserts but by the mid-1960s, titanium was starting to be more widely used. This is lighter than steel but also very strong, providing the best of both worlds.

At this time, plates and screws were often removed after the bone had healed. This is because they could be large and bulky and their design carried the risk of necrosis of the surrounding bone area.

Current-Day Treatment

In many ways, the modern treatments for broken wrists is similar to 50 years ago. The principle of trying to immobilise the broken bone remains just as important, and in some cases surgery may still be required to pin the fracture together.

However, one of the key differences is the understanding that while the bone must remain stable in order to knit effectively, the surrounding soft tissue must also be considered. The wearing of heavy casts which completely immobilise the whole arms for long periods is now considered to be counterproductive.

Instead, although casts are still used on the wrist, they have been designed to be far lighter than before. This reduces the weight and pressure on surrounding tissues and makes it easier to move the rest of the arm around. Fingers can be moved, albeit in a reduced capacity to prevent the soft tissue complications that can be caused by total immobility for a prolonged period.

The 1950s were a decade that was extremely important for the development of surgical pins, plates and other fixations. Setting the foundations upon which future developments could be built,  progress was just starting to be made to identify lighter, more permanent implants.

Fast-forward to the modern day and many pins and plates are now left in-situ. Deliberately designed to be capable of remaining in the body forever, these fixings are light, durable and strong with the ability to fuse well with the surrounding bone.

Steady Progress

Modern treatments for broken wrists is based upon historic knowledge and unlike in other areas, sweeping changes haven’t particularly been made. Instead, surgeons have refined materials and techniques to improve upon what was used in the past. This together with an improved understanding of soft tissue damage means the outcome is far better compared to five decades ago.