The ankle joint is the junction of three bony structures: the distal ends of the tibia and fibula, forming a mortise-like cavity that receives the trochlea of the talus. Stability of the joint is due to the congruity of the osseous structures and associated ligaments. The tibia and fibula are bound by the ligamentous structures of the syndesmosis (interosseous membrane; anterior, posterior, and transverse tibiofibular ligaments) [14]. Powerful collateral ligaments stabilize the joint against stress: the medial malleolus is supported by the broad fan of the deltoid ligament and the plantar calcaneonavicular ligament (spring ligament); the lateral aspect of the joint is reinforced by the lateral complex which consists the anterior fibulotalar ligament (AFTL), fibulocalcaneal ligament (FCL), and posterior fibulotalar ligament (PFTL). The ankle joint is not a pure hinge. It moves as a rotatory hinge around the helical axis of the joint due to the asymmetric shape of the talus. To function properly, exact congruence is crucial. Ankle fractures are regarded as articular fractures even if there is no joint involvement. Nonanatomical reductions and restraints in the ankle joint may have major adverse effects as premature degeneration of the joint, as they alter the biomechanics of the joint and cause pathological compressive stress [15, 16]. Hence, competent anatomical reconstruction and reduction, often involving surgery, are required in order to prevent long-term sequels.

The two most widely used classification systems for ankle fractures are the Danis-Weber and AO-Müller and Lauge-Hansen systems [17–19]. According to Danis-Weber and AO-Müller, a fracture is classified based on the level of the fibular fracture in relation to the syndesmotic ligaments. The Lauge-Hansen classification [17] describes the trauma mechanism of fractures based on the position of the foot at the time of injury and the direction of the deforming force. There are five types of Lauge-Hansen fracture each with progressive stages of injury: supination adduction, supination external rotation, pronation external rotation, pronation abduction, and pronation dorsiflexion. This classification was initially proposed to guide the closed reduction of ankle fractures by reversing the injury mechanism. Although it can be useful in describing the pathomechanics of ankle injuries and inferring their stability [20], we find it too complicated for routine use. We favor the Danis-Weber classification in which a lateral malleolar fracture below the syndesmosis is designated a type A injury; a fracture at the level of the syndesmosis, a type B injury; and a fracture above the syndesmosis, a type C injury. The Maisonneuve fracture is a special case, as it involves a proximal fracture of the fibula, typically below the fibular head that is usually caused by an indirect pronation mechanism. In this type of fracture, a tear of the entire interosseous membrane of the lower leg, the syndesmosis, and the deltoid ligament destabilizes the ankle joint.

Evidence of an ankle fracture includes swelling, hematoma formation, and tenderness to pressure over the medial and/or lateral malleolus or over the proximal head of the fibula (proximal fibular fracture, the so-called Maisonneuve fracture). It can be hard, though, to differentiate a fracture from a more common ligamentous injury, especially during on-the-field evaluation. Visible malposition of the joint should be immediately reduced with manual axial traction, followed by joint immobilization in a splint or an appropriate alternative. Careful neurovascular status and associated soft tissue damage should always be assessed.

Plain radiographs are needed in practically all cases of a fracture or a sprain with ligamentous instability suspicion. Ottawa ankle rules, first introduced by Stiell et al. in 1992, serve as guidelines in terms of ruling out serious ankle and midfoot fractures [21]. Although useful to reduce costs and increase time effectiveness (e.g., decrease wait times) in the emergency department, they do not correspond to the diagnostic standard in Europe. We believe that the costs and low radiation dose do not overweigh the risk of missing a fracture, particularly in the athlete.

Standard x-ray imaging of the ankle joint should be performed in the anteroposterior and lateral views. The mortise view is not a true anteroposterior view – it is obtained with the leg internally rotated 15–20° to optimize visualization of the ankle joint without being overlapped by the fibula. Depending on the associated injuries that may be suspected, additional views or a lateral image of the foot (to rule out fifth metatarsal base fractures) may be indicated. Computed tomography (CT) can also be helpful for the evaluation of articular fractures. On the other side, magnetic resonance imaging (MRI) is not indicated on the acute setting, but it can be valuable later on for the assessment of associated cartilaginous or ligamentous injuries.

In the general population, treatment of ankle fractures involves open reduction and internal fixation (ORIF) or nonoperative treatment. The ideal treatment of ankle fractures in the athlete remains relatively undetermined as the options are affected by concerns such as time to full return to sporting activity, amount of time of immobilization required, and ability to rehabilitate while recovering and healing. We believe that surgical treatment offers the potential for a more rapid and healthy recovery than nonsurgical management, allowing for early rehabilitation and preventing the deleterious effect of joint immobilization (muscle inactivity, osteopenia, joint stiffness, etc.). Nevertheless, any stable fracture with non-displaced or only slightly displaced fragments can be treated conservatively. The key factor to long-term success of treatment, regardless of the chosen method, is anatomical reduction [13]. In our practice, surgical reduction with rigid internal fixation is recommended to athletes with ankle fractures with bone displacement greater than or equal to 3 mm or if the athlete is especially concerned about a rapid return to activity. Usually, after the surgical reduction to an anatomic position, Danis-Weber type A and B injuries are fixated with a plate and cortical lag screws with or without interfragmentary screws. For Danis-Weber type C fractures, the fibula is reduced and fixated in a manner identical to that of the type A and B fractures. If the syndesmosis is unstable to external rotation following fixation of the Danis-Weber C fibula, then we insert one or two syndesmosis screws or knotless suture fixation systems. Bimalleolar fractures require appropriate reduction and fixation of the fibula as described, as well as reduction and fixation of the medial malleolus with lag screws. Bimalleolar equivalent injuries are treated according to the protocol of type B fractures, with additional repair of the deltoid ligament with large absorbable suture, if the mortise remains unstable after fibular fixation. Early postoperative functional treatment and physiotherapy are advised to improve joint function and proprioception (especially in athletes with combined ligamentous injuries). Full return to sports is likely 12–16 weeks after the injury.

In a Cochrane Review, which included three randomized and one quasi-randomized trial with 292 patients, the complications of nonoperative treatment included malunion, nonunion, pain, loss of function, muscle atrophy, cartilage degeneration, stiff/swollen joint, deep vein thrombosis (DVT), and pulmonary embolism (PE) [22]. Postoperative wound infections are the most commonly reported complication. Other complications reported include insufficient primary osteosynthesis, soft tissue necrosis, DVT, delayed union, nonunion, secondary displacement, refracture, stiffness, muscular atrophy, tendinous insufficiency, sensory deficit, tarsal tunnel syndrome, and complex regional pain syndrome type 1 [23] (Fig. 12.2).

The distal portion of the tibia is known as the plafond, which, along with the medial and lateral malleoli, forms the mortise to articulate with the talar dome. The plafond is concave in the anteroposterior plane and convex in the lateral plane. It is wider in the anterior plane to provide stability, especially while weight bearing (vide Ankle Fractures).

The two most commonly used classification systems are based on fracture patterns as seen on the radiograph: the Ruedi and Allgower [26] and the AO/OTA group classifications [27].

Ruedi and Allgower proposed the first of these classification systems in 1969. It is the classification system we use more often. Fractures are separated according to the degree of articular displacement as below:

Type 1: Simple cleavage-type fracture with little or no articular displacement

Type 2: Mild to moderate displacement of articular surface but minimal or no comminution of the articular surface or adjacent metaphysis

Type 3: Comminution of the articular surface and metaphysis with significant impaction of the metaphysis

It is also crucial to assess and grade the amount of soft tissue damage, according to the Tscherne classification [28].

The most common signs and symptoms are pain, swelling, deformity, and crepitus about the ankle, along with the inability to bear weight. Neurovascular examination should include pulses and capillary refill and assessment of sensation and ability to move the toes. An assessment for compartment syndrome should also be performed, as often there is significant soft tissue injury with a tibial plafond fracture.

In the first instance, multi-view radiographs including the foot, ankle (AP, mortise, and lateral views), and full-length leg views should be obtained. CT scans are particularly important and are necessary in most cases.

The main goals of treatment are the reestablishment of articular congruity, stable fixation with anatomic reduction, prevention of soft tissue complications, and rapid return to function. This requires operative intervention in most cases. Acute ankle external fixation followed by delayed reconstruction of the tibial plafond with plating or limited internal fixation combined with external fixation is the primary treatment option in cases of extensive soft tissue injury. Long leg cast may be an acceptable treatment in patients with isolated, non-displaced fractures. Acute ORIF should be limited to low-energy fracture patterns with minimal soft tissue injury or swelling. Early motion is usually delayed 7–10 days following treatment for soft tissue considerations. Generally, in intra-articular fractures, weight bearing is restricted in the first 8 weeks. Intensive physiotherapy exercise regimes play an integral role in rehabilitation. Although satisfactory long-term outcomes are usually expected in the general population, tibial plafond fractures can be disastrous to the professional athlete.

The calcaneus is the largest bone in the hindfoot. It articulates with the talus superiorly and the cuboid anteriorly and shares a joint space with the talonavicular joint, appropriately called the talocalcaneonavicular joint. The calcaneus transfers most of the body weight from the lower limb to the ground and acts as a lever for the force generated by the calf muscles.

As reported by Sanders, the classification of Essex-Lopresti divides intra-articular fractures into two types: tongue type (tuberosity fragment attached to the articular fragment) or joint depression (when it is not). Sanders further classified fractures according to the number and location of posterior facet articular fragments on CT [30].

Patients usually present after a fall from a height with complaints of severe heel pain and a variable degree of swelling. The integrity of the soft tissues should be assessed. Patients can also develop compartment syndrome in the “calcaneal compartment,” which, if left untreated, can lead to claw toe deformities.

Patients should be assessed initially with plain radiographs, including lateral and axial Harris views of the hindfoot. An oblique view can be helpful for visualizing the calcaneocuboid joint. If these radiographs reveal an intra-articular component to the fracture, a computed tomographic scan should be made.

The treatment of displaced intra-articular calcaneal fractures can be divided into three categories: nonoperative, open reduction and internal fixation, and primary arthrodesis. Extra-articular fractures can be treated nonoperatively with immobilization and non-weight bearing, unless the fragments are substantially displaced or impede soft tissue function, as is the case of the calcaneal tuberosity fracture still attached to the Achilles insertion. Intra-articular fractures should be treated operatively. The primary goals of surgery are to restore bony geometry (i.e., height and width) and joint congruity.

The forefoot is comprised of five metatarsal bones and the phalanges of each toe. The midfoot consists of five bones: three cuneiforms (medial, middle, and lateral), the cuboid, and navicular. The Lisfranc joint consists of the articulations between the metatarsals and the three cuneiforms and cuboid. Its osseous architecture and soft tissue connections are critical to the stability of the foot. Soft tissue support of the tarsometatarsal (TMT) articulation consists primarily of capsular and ligamentous structures. The Lisfranc ligament is the most important and runs from the plantar medial cuneiform to the base of the second metatarsal. Injury to this ligament can destabilize the entire forefoot as well as the Lisfranc articulation [32].

In 1909, Quenu and Kuss first described injuries to the TMT joint based on the direction of displacement at the metatarsotarsal joint [33]. Myerson et al. classified these injuries into different types to aid in clinical decision-making [34]:

Type A – total incongruity of the TMT joint

Type B1 – partial incongruity affecting the first ray in relative isolation (i.e., partial medial incongruity)

Type B2 – partial incongruity in which the displacement affects one or more of the lateral four metatarsals (i.e., partial lateral incongruity)

Types C1 and C2 – a divergent pattern, with partial or total displacement

Athletes with Lisfranc or other midfoot fractures will complain of midfoot pain of immediate onset and present a subsequent inability to weight bear and midfoot swelling. Classic findings of Lisfranc fracture include forefoot and midfoot edema and plantar arch ecchymosis.

Computed tomography (CT) may supplement standard radiographic examination if there is need for further description and surgical planning. The images will typically reveal diastasis between the hallux and the second toe on an anteroposterior (AP) foot radiograph – a “positive gap sign” [32] – and/or multiple fractures along the TMT joints along with suggestions of ligamentous instability.

Unstable Lisfranc injuries should be treated surgically with either transarticular fixation to restore anatomical alignment and stabilize the tarsometatarsal joints or arthrodesis, depending on ligamentous or bony injury and comminution. Postoperatively, patients are frequently placed in a short leg cast for up to 4 weeks. Physical therapy to regain balance, strength, and ROM is recommended. Customarily, athletes needing surgical fixation of a Lisfranc fracture-dislocation should expect to be sidelined for at least 12–16 weeks [31] (Fig. 12.3).