Ankle fracture

Last updated: August 9, 2023

Summarytoggle arrow icon

Ankle fractures are the most common fractures of the lower extremity and most often result from twisting the ankle. Clinical features include ankle pain and decreased range of motion. If the patient history and physical examination are both consistent with a fracture (e.g., the patient is unable to bear weight on the affected leg), an x-ray is performed. The most important diagnostic consideration is whether the fracture is stable (e.g., isolated malleolar fractures) or unstable (e.g., bimalleolar fracture). Unstable fractures require surgery, whereas stable ones can be treated conservatively with a short leg cast.

Etiologytoggle arrow icon

Classificationtoggle arrow icon

Types of ankle fractures [1]

Ankle fracture stability [3]

The ankle becomes increasingly unstable with worsening severity of injury. Generally, fractures at two or more sites are unstable.

Weber classification of ankle fractures [1]

The Weber classification categorizes ankle fractures according to the level of the fibular fracture in relation to the distal tibiofibular syndesmosis.

Maisonneuve fractures are considered Weber C fractures. [1]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Clinical evaluation [1]

Perform the following prior to imaging as abnormalities can affect urgent management (see “Approach” in “Treatment”):

Examine the entire length of the fibula in patients with ankle pain to evaluate for a Maisonneuve fracture. [1]

Ottawa ankle and foot rules [4][5]

These criteria are used to determine the need for X-rays in patients presenting to the emergency department (ED) with traumatic ankle and/or foot injuries. [4][5]

X-ray [1]

Advanced imaging [1]

Differential diagnosestoggle arrow icon

Treatmenttoggle arrow icon

Approach [1]

Stable, isolated, nondisplaced fractures can be initially managed with immobilization and orthopedic follow-up within 48 hours.

Repeat the neurovascular exam after reduction and again after immobilization.

Overview [1]

Overview of ankle fracture management [1]
Fracture type Initial immobilization Weight-bearing status Disposition

Isolated lateral malleolus

Weber A

Walking boot


Orthopedic follow-up within 48 hours

Weber B or Weber C

Posterior short-leg splint or CAM boot


Urgent orthopedics consult OR orthopedic follow-up within 48 hours

Isolated medial malleolus

Posterior short-leg splint or walking boot

Orthopedic follow-up within 48 hours

Isolated posterior malleolus

Posterior short-leg splint with or without stirrup splint

Bimalleolar fracture

Urgent orthopedics consult OR orthopedic follow-up within 48 hours

Trimalleolar fracture

Urgent orthopedics consult

Pilon fracture

Maisonneuve fracture

Posterior long-leg splint

Urgent orthopedics consult OR orthopedic follow-up within 48 hours

Conservative treatment [1]

See “Conservative treatment of fractures” for further details.

Surgical treatment [1]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  2. Dietrich G, Prod’homme M, Müller J, Ballhausen T, Helfer L. Conservative management of a specific subtype of Maisonneuve fractures: a report of two cases. AME Case Reports. 2022; 6: p.17-17.doi: 10.21037/acr-21-67 . | Open in Read by QxMD
  3. Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures. EFORT Open Reviews. 2018; 3 (5): p.294-303.doi: 10.1302/2058-5241.3.170057 . | Open in Read by QxMD
  4. Stiell IG. Decision Rules for the Use of Radiography in Acute Ankle Injuries. JAMA. 1993; 269 (9): p.1127.doi: 10.1001/jama.1993.03500090063034 . | Open in Read by QxMD
  5. Bachmann LM. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003; 326 (7386): p.417-417.doi: 10.1136/bmj.326.7386.417 . | Open in Read by QxMD
  6. Ankle radiograph (an approach). Updated: January 1, 2016. Accessed: December 8, 2016.

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