Injuries sustained during friendly sporting fixtures can be particularly distressing as they may preclude subsequent participation in a major event. This spring has seen some Euro 2016 warm-up matches and whilst A Year on Foot at the ISEH may not be a soccer aficionado, a chance viewing of a recent international saw the England and Stoke goalkeeper stretchered off with an ankle injury. The injury mechanism seemed indistinct and his ability to bear weight meant the severity could be under-estimated, but subsequent media posts reported a fractured ankle treated operatively with three screws.
Fractures of the ankle affect the bony malleolar prominences at the lower end of the tibia and fibula and their articulation with the central ankle talus bone in a structure which is analogous to a wood-work mortise and tenon joint. The integrity of the joint is stabilised by the ligaments and syndesmosis considered by A Year on Foot at the ISEH 2 which maintain the bony relationships of the ankle mortise. The principles of ankle fracture treatment are based on the amount of displacement or distance the bony fragments are separated and the number of different parts of the joint injured - a combination of bone and ligament damage can act together to render a joint unstable necessitating surgical rather than non-operative treatment for stable injuries.
In the clinical assessment of an ankle problem, a description of the limb position and injury mechanism may predict the pattern of fractures and ligament tears. The ability to bear weight during walking after an injury can also indicate its severity and stability. Swelling, bruising and bony tenderness require further assessment with an X-ray of the joint. Inconclusive findings or complex patterns may require more detailed assessment with Computerised Tomography (CT) or high definition Magnetic Resonance Imaging (MRI) which can help direct treatment and predict possible longer term sequelae.
Stable fracture pattern injuries can be treated using a cast or pneumatic walker boot for six to eight weeks until the bone healing biology starts to form strong new bone or callus - a return to contact sport would be rare before three to four months’ time. Surgical treatment for unstable injury patterns follows basic orthopaedic operative principles, with the choice of hardware selected according to the size of fracture fragments and the forces acting on them. The slender outer fibula bone usually requires fixation with a combination of plates and screws whilst the inside medial tibial malleolus is usually addressed with screws. Concomitant injury of the syndesmosis, leading to a diastasis or separation of the fibrous tibiofibular joint similar to a ‘high ankle sprain’, requires fixation with screws or a ‘Tight-rope’ suture button. A complex ankle fracture pattern with surgical fixation can require six to twelve weeks’ immobilisation in a cast or pneumatic walker - a return to competitive contact sport might be delayed by at least six to nine months.
The three screws required to fix the fracture on our International goalkeeper’s ankle has still left A Year on Foot at the ISEH pondering about which fracture type would be treated in this way. A large vertical fracture fragment of the inside medial tibial malleolus would be an unusual but possible pattern and can occasionally represent a stress injury, related to a repetitive inward tilting adduction force. An alternative injury pattern would be a combination of a medial malleolus fracture combined with a syndesmosis injury, eponymously called a Maisonneuve fracture. This specific injury can be associated with a fibula fracture which is very high up in the bone towards the knee and is easily missed on an ankle X-ray alone. An X-ray displaying the whole length of the tibia and fibula may be necessary to demonstrate the extent of the injury. A third possible pattern would be an outward or external rotation twisting mechanism which can cause the tibiofibular ligaments to pull off a piece of bone from the tibia - called a Tillaux fracture in adolescence but in the skeletally mature adult it can occur in combination with a syndesmosis injury.
For an injury sustained during a warm-up friendly fixture, neither titanium or steel hardware, or surgical bravura can accelerate the basic time-dependence of healing after an ankle fracture with its resultant delay in return to competitive sport. On a positive note, however, A Year on Foot at the ISEH recalls the amazing qualities of bone in being one of our body’s few tissues which heals with true regeneration of ‘like for like’ bone tissue rather than repair with a scar of inferior quality and structure.
Mr Michael Oddy, Consultant Trauma & Orthopaedic Surgeon