What is the treatment for a spiral fracture of the ankle?

Treatment of Spiral Fracture of the Ankle

For spiral ankle fractures, treatment depends critically on fracture stability: stable fractures (intact ankle mortise, no deltoid ligament injury, isolated lateral malleolus) can be managed conservatively with functional support and early mobilization, while unstable fractures require surgical fixation, particularly when associated with tibial shaft involvement or posterior malleolar fragments. 1, 2

Initial Assessment and Imaging

Diagnostic Evaluation

• Obtain standard ankle radiographs to assess fracture pattern, displacement, and ankle mortise integrity 3
• Look specifically for:
  • Medial clear space widening (>4mm suggests deltoid ligament injury) 1
  • Talocrural angle abnormalities
  • Associated posterior malleolar fractures
  • Concomitant tibial shaft involvement 2

Advanced Imaging Indications

• CT scanning is essential for spiral tibial shaft fractures as 64.7% have concomitant ankle injuries requiring surgical fixation 2
• CT detects posterior malleolar fractures and syndesmotic injuries missed on plain radiographs (78-87% sensitivity for radiographs vs near 100% for CT) 3
• MRI is reserved for persistent pain with negative radiographs or suspected occult ligamentous injury 3

Conservative (Non-Operative) Treatment

Indications for Conservative Management

Conservative treatment is appropriate when ALL of the following criteria are met: 1

• Intact ankle mortise in both AP and lateral projections
• No significant deltoid ligament injury (medial clear space <4mm)
• No other fractures within the ankle region
• Isolated lateral malleolus spiral fracture (Weber B)

Conservative Treatment Protocol

• Use removable functional support (ankle brace) for 4-6 weeks rather than rigid cast immobilization 3
• Ankle braces show superior outcomes compared to elastic bandages or tape (RR 4.19-5.48 for reduced swelling) 3
• Begin early weight-bearing as tolerated to improve ankle dorsiflexion range of motion 4
• Initiate exercise therapy immediately to prevent recurrence (RR 0.37 for recurrent injury with exercise) 3

Pain Management

• NSAIDs (naproxen 500mg twice daily or celecoxib) are first-line for pain control and improved function 3
• Paracetamol is equally effective as NSAIDs with fewer side effects 3
• Apply ice/cryotherapy during acute phase (first 72 hours) for edema reduction 3

Surgical Treatment

Indications for Surgery

Immediate surgical referral is required for: 1, 2

• Unstable ankle mortise (widened medial clear space)
• Deltoid ligament rupture
• Bimalleolar or trimalleolar fractures
• Spiral tibial shaft fractures (64.7% have associated ankle injuries requiring fixation) 2
• Posterior malleolar fragments involving >25% of articular surface
• Blue, purple, or pale extremity (vascular compromise) 3

Surgical Approaches for Spiral Fractures

• For posterior malleolar fragments in spiral tibial shaft fractures: posteroanterior lag screws or posterior buttress plate via posterolateral approach achieve equivalent outcomes (AOFAS scores 92.5 vs 94.7) 5
• Circular external fixation is effective for distal tibia-fibula spiral fractures with mean treatment time of 18.8 weeks 6

Post-Immobilization Rehabilitation

Following Conservative or Surgical Management

• Exercise therapy should begin immediately after immobilization period to prevent recurrence and improve function 3
• Functional support reduces return to work time by 8.23 days compared to immobilization 3
• Return to sport occurs 4.88 days earlier with functional treatment 3

Monitoring for Complications

• Watch for cast-associated skin breakdown (14% incidence with total contact casts in high-risk patients) 3
• Monitor for signs of compartment syndrome or neurovascular compromise
• Repeat imaging only if new trauma, increased pain, or neurovascular symptoms develop 7

Critical Pitfalls to Avoid

• Do not miss associated tibial shaft fractures: All spiral ankle fractures warrant careful examination of the entire tibia, as spiral tibial shaft fractures have 64.7% incidence of ankle injuries 2
• Do not use prolonged immobilization (>10 days): Casts beyond 10 days lead to worse outcomes than functional treatment 3
• Do not assume stability based on radiographs alone: CT is necessary for spiral tibial shaft fractures to identify occult posterior malleolar and syndesmotic injuries 3, 2
• Do not use removable braces in non-compliant patients: Non-adherence leads to progressive deformity and delayed healing 3