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By Dr. Jeff HershMore Content NowQ: My father broke his ankle and they said he needs surgery. Why can�t they just put it in a cast and let it heal on its own?A: The ankle joint is made up of three bones. The tibia (shin bone) and fibula extend downward from the calf to form a �pocket� in which the talus (which sits on top of the heel bone, also called the calcaneus) snuggly fits. All these are held together by multiple ligaments (the ligaments holding the tibia and fibula together make up the syndesmosis joint). The end of the fibula forms the outside (lateral) part of this �pocket,� the end of the tibia forms the back (posterior) and inside (medial) parts. The extended parts of the fibula and tibia that surround the talus are called malleoli (singular malleolus). The open part in front of this �pocket,� along with cushioning in back (cartilage), allows the foot to smoothly hinge up and down, and of course, there is some limited side-to-side movement possible as well. This is why the ankle is strong, yet flexible enough to carry all the forces needed for us to stand, walk, run and do whatever other crazy things we put our bodies through (sports, etc.).An ankle fracture occurs when there is a break of one or more of the three ankle bones. It usually occurs from a disruptive force on the joint from a fall, direct impact, or �rolling� the ankle (putting too large a twisting force on it).However, all these types of injuries more commonly cause an ankle sprain (where the ligaments are partially or completely torn but the bones are intact) rather than a fracture. Both an ankle sprain and fracture may become black and blue and have pain, swelling (despite folklore to the contrary the amount of swelling is not a reliable way to differentiate a sprain from a fracture) and tenderness. Except for swelling, the ankle will not be deformed by a sprain, but the joint can be subtly or even grossly deformed by a fracture.A good history and physical exam are usually enough to determine when a fracture is unlikely (so only a sprain is suspected). Specifically, the �Ottawa ankle rules� note that a fracture is very unlikely if the patient can bear weight immediately after the injury and when they are subsequently evaluated in the emergency department, and there is no bony tenderness on the back part of the medial or lateral malleoli.If a fracture is unlikely, no x-ray is needed and the patient is treated for a sprain with RICE; rest, immobilization (whether an ace wrap or in some severe cases a splint and crutches), compression and elevation/ice to reduce swelling.Annually, almost two per 1,000 Americans break their ankle. Thankfully, about two thirds of these are uni-malleolar fractures (only one malleolus is broken), but about 20 percent are bi-malleolar (two malleoli are broken) and up to 10 percent are tri-malleolar (all three malleoli are involved).Page 2 of 2 - If a fracture is suspected, the best initial imaging test is an x-ray, although in some cases, a CT or even an MRI may be indicated. A �stress� x-ray (where images are obtained while there is force applied to the joint, say from standing, etc.) may be needed to help determine if the joint is stable or not.Once an ankle fracture is diagnosed, the next step is to determine if there are any complications (such as an open fracture where the bone protrudes through the skin, or a nerve, blood vessel or other critical injury), which require immediate surgery. If this is not the case, the ankle fracture is evaluated for stability.An isolated lateral malleolar fracture (the most common ankle fracture) is stable if the fibula is not knocked out of normal position (is not displaced) and there is no significant disruption of the other structures. It is treated like a sprain.Isolated medial or posterior malleolar fractures may be stable, but since it takes more force to break these bones they are not uncommonly unstable. Any fracture that involves two or more sites of significant injury (such as bi- or tri-malleolar factures) is usually unstable.Unstable ankle fractures typically require surgery to realign the ankle bones, stabilize the joint and reduce the chances of mal-union (where the bones heal in a non-optimal fashion). 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