Editor - Colin Blythe.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.