Foot & Ankle Fractures

Foot and ankle fractures involve disruption of the bony architecture of the distal leg, hindfoot, midfoot, and forefoot. Several distinct fracture entities warrant separate discussion.

Ankle Fractures

Ankle fractures involve the malleoli — the medial malleolus (distal tibia), lateral malleolus (fibula), and/or posterior malleolus (posterior tibial lip). Two classification systems guide management:

• Weber/AO Classification categorizes fibular fractures by their relationship to the ankle mortise (syndesmosis): Weber A (below the syndesmosis, typically stable), Weber B (at the level of the syndesmosis, variable stability), and Weber C (above the syndesmosis, usually unstable with syndesmotic disruption).
• Lauge-Hansen Classification describes the mechanism of injury (e.g., supination-adduction, pronation-abduction) and predicts the pattern of ligamentous and bony injury, guiding surgical planning.

Ankle fracture patterns include:

• Lateral malleolus fracture: Most common isolated ankle fracture; stability depends on medial-sided integrity.
• Medial malleolus fracture: Often associated with lateral ligamentous injury or fibular fracture.
• Bimalleolar fracture: Involves both medial and lateral malleoli; mortise is typically unstable.
• Trimalleolar fracture: Adds a posterior malleolus fragment, which, if large (>25% of the articular surface), may require fixation.

Operative vs. Non-Operative Decision: The Ottawa Ankle Rules guide X-ray triage — point tenderness at the posterior malleolus or malleolar tips with inability to bear weight warrants imaging. Non-operative management (cast or boot) suits truly stable fractures with an intact mortise and minimal displacement (<2 mm). Unstable fractures, those with mortise widening, or bimalleolar/trimalleolar patterns typically require open reduction and internal fixation (ORIF). Syndesmosis injury — disruption of the tibiofibular ligament complex — must be identified (stress X-ray, CT, or intraoperative assessment) and fixed with screws or tightrope constructs to prevent chronic instability.

Fifth Metatarsal Fractures

These are the most common metatarsal fractures and fall into two clinically important categories:

• Avulsion fracture (at the tuberosity, Zone 1): Caused by peroneus brevis pull-off with ankle inversion. Excellent healing prognosis with protected weight-bearing in a stiff-soled shoe or walking boot for 4–6 weeks.
• Jones fracture (metaphyseal-diaphyseal junction, Zone 2): Occurs in an area of poor vascular supply. Significantly higher risk of delayed union and non-union. Non-athletes can be managed non-operatively with strict non-weight-bearing cast 6–8 weeks, though healing is slow. Athletes and high-demand patients are generally offered early intramedullary screw fixation, which accelerates return to sport and reduces non-union risk.

This distinction — Zone 1 vs. Zone 2 — is not cosmetic; it drives fundamentally different treatment plans and prognoses.

Calcaneal Fractures

The calcaneus (heel bone) is the most commonly fractured tarsal bone, typically from axial loading (fall from height, motor vehicle collision). The primary distinction is:

• Extra-articular fractures: Do not involve the posterior facet of the subtalar joint. Generally managed conservatively with non-weight-bearing and protected mobilization; outcomes are favorable.
• Intra-articular fractures: Involve the posterior facet and account for ~75% of calcaneal fractures. These injuries flatten the heel (decreased Böhler's angle), widen the hindfoot, and peroneal impingement is common. CT scanning is essential for surgical planning. ORIF through an extensile lateral approach or percutaneous/minimally invasive techniques can restore articular congruity. Not all patients are surgical candidates — poor soft-tissue condition, smoking, and diabetes significantly increase wound complication risk. Non-operative management remains appropriate for many patients, though malunion and subtalar arthritis remain risks.

Treatment options

Treatment depends on which bone is broken and how much it has moved out of place.

Frequently Asked Questions