Ankle fractures

I spent two hours today shadowing, and the main topic of the day was the Weber Classification System for ankle fractures. A Weber fracture will either be labeled A, B, or C. Here is a great picture showing the differences between the three:



Just to orient you to what you are looking at, this is the top part of your ankle where it meets your leg bones. The long skinny bone on the left is one leg bone called the fibula, and the long wider bone is the tibia (your shin bone). That big bony bump on the lateral side of your ankle (the side facing out toward the world, as opposed inside the two legs) is called your lateral malleolus, which is the bottom of the fibula.

Weber fractures occur usually when a person rolls their ankle. The patient we saw today rolled hers while stepping down from a curb. Weber As are better to have than Weber Cs, for healing purposes. A lot of times in a Weber C, you break not only the fibula, but the medial malleolus as well. That is the big bony bump on the inside of your ankle.



When dealing with an ankle fracture, you have to be concerned about the ankle mortise, or the space between your tibia and the first ankle bone called the talus. Here is a picture:


Do you see that clear space in between leg bone and the ankle bone? Well, when you break your ankle, sometimes that space because wider in some places. This is of concern because the more space in between those two bones, the more freedom the bones have to move around, which can lead to instability. You don't want your shin bone slipping around when you are planting your foot, you want it to stay where it should be. Here is a picture of that mortise space being enlarged:


If you compare the two pictures, you can see that in the bottom one, the space in between the leg bone and ankle bone is much greater than in the picture above it.

If you get a B or C Fx (Fx means fracture), you might need screws to help keep the joint stable. Here is an xray of some examples of that:


The above is a Weber B fracture. Below is a Weber C, which has to include an extra screw to help with that medial malleolus:



For a Weber A Fx, you usually won't need surgery, just a walking boot for 6-8 weeks while the fibula heals. Click here for treatment of ankle fractures, and here for followup of ankle fractures.

When it comes to x-raying ankle fractures, there are guidelines known as the Ottawa Rules to determine if it needs to be x-rayed. However, I was told that if there's an injury and there is pain and swelling, most people x-ray just to avoid being sued. Here are the rules anyway (from http://www.gp-training.net/rheum/ottawa.htm):

An ankle x-ray is required only if there is any pain in malleolar zone and any of these findings:

• bone tenderness at A
• bone tenderness at B
• inability to weight bear for four steps both immediately and in the casualty department.

A foot x-ray is required if there is any pain in the midfoot zone and any of these findings:

• bone tenderness at C
• bone tenderness at D
• inability to weight bear for four steps both immediately and in the casualty department.

So there's that. The other cases were mainly wrist fractures. We saw a girl who had broken her wrist enough that the bones had to be put in place (her wrist had to be reduced), but her cast was really uncomfortable and she wanted it changed. Unfortunately, if a fracture has been reduced, you can't open the cast up again, because the bones could just pop right back out. We were able to hook her up with a better sling than the one she had from the ER to help with make her arm more comfortable.

We saw a boy who was having wrist pain over the place where he broke his wrist three years prior. The xray didn't show any new fractures (and actually you couldn't even really see his old fracture, thanks to how well bones grow and realign themselves in children), but to give the wrist some rest, we casted it anyways.

We saw a followup for a woman who had broken her wrist two weeks prior. The fracture was healed, so we took her cast off and put it in a splint.

The last patient we saw was a followup from a severe ankle sprain that had occured four weeks prior, which was still painful, although getting better. We gave her a new prescription for physical therapy (since she hadn't done it when she initially hurt her ankle), and she was to come back again in three weeks to see if anything had changed. Her PT program was to include work conditioning, which is when your PT is specialized towards the motions that the person would do in their regular work day. For example, this woman talked about having to walk down a hill, so PT would include that in strengthening.

Other than that, I am happy to report that I am almost over that nasty cold I had. Thank goodness :)