Advancements in the diagnosis and management of complex trimalleolar ankle fractures: A comprehensive review

Abstract

Complex trimalleolar ankle fractures are a major orthopaedic challenge, with an incidence of 4.22 per 10000 person-years in the United States and an annual cost of 3.4 billion dollars. This review synthesizes current evidence on diagnostic protocols and management strategies, highlighting optimal approaches and emerging trends. Initial care emphasizes soft tissue assessment, often guided by the Tscherne classification, and fracture classification systems. External fixation may be required in open injuries, while early open reduction and internal fixation within six days is linked to improved outcomes. Minimally invasive techniques for the lateral malleolus, including intramedullary nailing and locking plates, are effective, while medial malleolus fractures are commonly managed with screw fixation or tension-band wiring. Posterior malleolus fragments involving more than 25% of the articular surface usually warrant fixation. Alternatives to syndesmotic screws, such as cortical buttons or high-strength sutures, reduce the need for secondary procedures. Arthroscopic-assisted open reduction and internal fixation benefits younger, active patients by enabling concurrent management of intra-articular and ligamentous injuries. Postoperative care prioritizes early weight-bearing and validated functional scores. Despite advances, complications remain common, and further research is needed to refine surgical strategies and improve outcomes.

Key Words: Trimalleolar ankle fractures; Complex ankle fractures; Trimalleolar fractures; Fibula fractures; Tibia fractures

Core Tip: The management of trimalleolar ankle fractures is often complex, with high incidence rates and substantial economic impact. Advanced imaging techniques, particularly computer tomography, have improved fracture assessment, influencing surgical planning and outcomes. Surgery management remains the gold standard, with timing and techniques being crucial to minimize complications and costs.

INTRODUCTION

Complex ankle fractures pose significant challenges for clinicians, yet there remains a lack of clear, internationally accepted guidelines for either surgical or conservative management[1-3]. In the United States, ankle fractures occur at an incidence of 4.22 per 10000 person-years, accounting for approximately 3.4 billion dollars in annual healthcare expenditures[1]. In Sweden, ankle fractures represented 10.3% of all adult fractures between 2015 and 2018, with an incidence of 126.6 per 100000 individuals[2,3].

Complex ankle fractures represent 11% to 14% of all ankle fractures, with peak incidence between ages 50 and 69[3,6]. Among women, incidence is highest between ages 75 and 84[3,6]. Isolated unimalleolar fractures account for about 70% of cases, bimalleolar for 20%, and trimalleolar for 7%, while open ankle fractures comprise around 2% of cases[1-7]. The average cost per fracture is 27534 ± 19170 dollars, with 59% direct medical costs and 41% indirect costs from missed work[7]. Patients undergoing operative treatment incur significantly higher total (35413 dollars) and direct (23938 dollars) costs compared to those treated nonoperatively (14860 dollars and 3611 dollars, respectively), and also experience longer work absences[7].

For many patients, complex ankle fractures are life-altering injuries with profound effects on social and occupational functioning. Approximately 17.6% of previously employed individuals lose their jobs, and despite rehabilitation, 47% do not return to work within 5 years of injury[4]. Physical sequelae may include chronic pain, functional limitations, altered gait, and early post-traumatic arthritis, while psychological distress is also frequently reported[5]. These injuries are further associated with high complication rates and substantial morbidity and mortality[1-7]. Surgical intervention is typically indicated for unstable fracture patterns. However, ongoing debate surrounds both diagnostic approaches, such as the role of computed tomography, and optimal surgical techniques based on fracture type and patient-specific factors[1-7].

As such, this narrative review aims to provide a comprehensive state-of-the-art review of trimalleolar ankle fractures, focusing on the most widely utilized diagnostic protocols and treatment approaches. By exploring the current literature and examining the efficacy and outcomes of different interventions, this review synthesises current evidence on the diagnosis and management of trimalleolar ankle fractures, highlighting optimal strategies, contemporary practices, and emerging treatment trends.

METHODOLOGY

A narrative review was conducted using PubMed (MEDLINE), Scopus, EMBASE, Cochrane Library, Google Scholar, and Web of Science. Keywords such as “complex ankle fractures”, “ankle fractures”, “management”, “trimalleolar”, “treatment”, “timing”, “protocols”, and “surgery” were used in various combinations to identify relevant studies. Three independent authors, blinded to each other’s selections, screened all articles published up to December 2022. Reference lists of included studies were also reviewed to identify additional relevant publications. Only studies published in English were considered. Articles with abstracts deemed relevant were retrieved in full for detailed evaluation. Additional sources included manual searches of contemporary orthopaedic textbooks, conference proceedings, and recent scientific meeting abstracts.

SUMMARY

Table 1 summarizes aetiology, classifications, and diagnostic approaches, while Table 2 outlines treatment options by fracture component. In addition, Table 3 presents a summary of optimal management approaches under different clinical scenarios, consolidating key practical recommendations for ease of reference.

Table 1 Key points.

Section	Key points
Epidemiology and costs	High incidence in older adults, significant economic burden
Aetiology	Commonly caused by twisting, falls, or impact injuries
Classification	Multiple systems used (Pott, Lauge-Hansen, Weber, AO, CT-based)
Clinical evaluation	Pain, swelling, neurovascular risk; Tscherne classification guides soft tissue care
Diagnosis	Radiographs first-line; CT critical for surgical planning
Damage control	External fixation stabilizes open/high-risk fractures; Illizarov allows early weight-bearing
Timing of ORIF	ORIF within 6 days improves outcomes; delayed surgery raises infection risk
Lateral malleolus	Intramedullary nailing preferred for high-risk patients; locking plates also effective
Medial malleolus	ORIF standard; conservative treatment possible if anatomically reduced
Posterior malleolus	Fragment size and type guide fixation; direct posterior approach preferred for large PMF
Syndesmosis	Dynamic fixation (suture buttons) preferred over screws in some cases
Arthroscopy	Useful in active patients for intra-articular injury management
Deltoid ligament	Repair improves medial stability; especially in multi-ligamentous injuries
Postoperative care	OMAS, AOFAS scores used; early weight-bearing improves recovery but risks complications
Complications	Includes DVT, sepsis, MI, AKI; occur mostly within 30 days post-op

AO: Arbeitsgemeinschaft fur osteosynthesefragen; CT: Computed tomography; ORIF: Open reduction internal fixation; PMF: Posterio malleolar fracture; OMAS: Olerud-Molander Ankle Score; AOFAS: American Orthopaedic Foot and Ankle Score; DVT: Deep vein thrombosis; MI: Myocardial infarction; AKI: Acute kidney injury.

Table 2 Summary of treatment options for trimalleolar ankle fractures by fracture component.

Fracture component	Main surgical options	Indications/notes	Advantages	Limitations/concerns
Lateral malleolus	Intramedullary fibular nailing; locking/antiglide plates	Weber B and C fractures; osteoporotic bone; high-risk soft tissue	Minimally invasive, preserves soft tissue, short operative time	Risk of hardware irritation; nail compliance issues
Medial malleolus	ORIF with single or dual screws; tension-band wiring; antiglide plating	Anatomically aligned vs displaced fractures; vertical/comminuted patterns (Herscovici types B-D)	Stable fixation, simple technique	Wire migration, need for hardware removal; risk of non-union
Posterior malleolus	Posterior plating (buttress/antiglide); anteroposterior screws	> 25% articular surface, talus dislocation, Haraguchi type II/III	Direct visualization, anatomical reduction, early weight-bearing	Increased operative time, wound complications
Tibiofibular syndesmosis	Cortical button fixation; high-strength suture constructs; traditional screws	Syndesmotic disruption or instability	Preserves physiological motion, less need for removal, fewer reoperations	Cost, learning curve; screw breakage if conventional fixation used

ORIF: Open reduction and internal fixation.

Table 3 Suggested management pathways for trimalleolar ankle fractures under different clinical scenarios.

Scenario	Recommended approach	Supporting evidence/rationale
Open fracture with significant soft tissue injury	Initial external fixation ± orthoplastic input → staged ORIF once soft tissues permit	Reduces infection/compartment risk; Illizarov frame allows early weight-bearing[35-39]
Closed fracture with marked swelling	Temporary external fixation → delayed ORIF (ideally within 6 days)	Early stabilization with lower soft-tissue complication risk[40-47]
Posterior malleolus fragment > 25% articular surface or type II/III Haraguchi	Direct posterior approach with buttress plate/antiglide fixation	Improved reduction and prevention of post-traumatic arthritis[86-93]
Elderly/osteoporotic patient with lateral malleolus fracture	Intramedullary nailing or minimally invasive locking plate	Minimizes wound complications; preserves soft tissue integrity[48-53]
Younger/high-demand patient	Arthroscopic-assisted ORIF	Allows detection/repair of intra-articular injuries, better functional outcomes[68-73]
High-grade syndesmotic injury	Cortical button or high-strength suture fixation	Restores stability, avoids need for screw removal, facilitates early rehab[64-67]
Associated deltoid ligament injury with medial instability	Deltoid ligament repair ± ORIF	Improves reduction and long-term stability; supported in athletic/complex cases[94-102]

ORIF: Open reduction and internal fixation.

AETIOLOGY

Ankle fractures can result from various mechanisms of injury, most commonly involving twisting, impact, or crush forces. These may occur during sports activities, falls from height, or tripping. The extent of bony comminution and soft tissue damage is generally proportional to the energy of the trauma, and the resulting fracture pattern is closely associated with the specific mechanism of injury[1-5].

CLASSIFICATIONS

Several classification systems have been developed to categorize ankle fractures based on varying criteria. Pott[8] introduced a simple system based on the number of malleoli involved, as unimalleolar, bimalleolar, or trimalleolar fractures. The Lauge-Hansen classification[9] describes fracture patterns according to the position of the foot and the direction of the applied force during injury. Danis-Weber[10] focuses on the level of the fibular fracture in relation to the tibiofibular syndesmosis. The (arbeitsgemeinschaft fur osteosynthesefragen) system[11] offers a comprehensive numerical coding approach applicable across fracture types. More recently, computer tomography (CT)-based classifications have been developed to assess posterior malleolar fractures with greater precision[12-15].

Clinical presentation and evaluation

Ankle fractures typically present with pain, swelling, deformity (which correlates with the degree of displacement), and, in high-energy injuries, may involve neurovascular compromise and significant soft tissue damage[1-3]. A thorough clinical assessment is essential, with particular attention to vascular and neurological status as well as the condition of the surrounding soft tissues. Soft tissue management in complex trimalleolar ankle fractures remains a key area of clinical debate. The integrity of the skin is a critical determinant of both the timing and nature of surgical intervention, as delayed wound healing can significantly complicate postoperative recovery.

The Tscherne classification system provides a standardized framework for evaluating soft tissue damage in both open and closed fractures, guiding decisions between immediate external fixation and acute open reduction and internal fixation (ORIF)[16]. Recent rehabilitation frameworks, such as the Protection, Elevation, Avoid Anti-Inflammatories, Compression, Education and Load, Optimism, Vascularization, Exercise protocols, have shifted away from traditional cryotherapy, emphasizing tissue healing and patient-centred care[17-22]. When fracture blisters are present, they should generally be left intact, as they tend to heal spontaneously[22]. Despite emerging recommendations, there remains no clear consensus on optimal soft tissue management, largely due to methodological limitations and bias within existing studies[23].

Diagnosis

Radiographs are typically the first-line imaging modality for evaluating ankle fractures. The Ottawa Ankle and Foot Rules[24] serve as a valuable clinical tool to help identify patients who require radiographic assessment, thereby reducing unnecessary imaging, healthcare costs, and patient wait times in the emergency department[25]. A complete radiographic evaluation should include anteroposterior, mortise, and lateral views[26-28], while computed tomography is essential for complex ankle fractures to accurately define fracture patterns and guide surgical planning, altering the operative approach or positioning in approximately 44% of cases compared to radiographs alone[25-29].

Particular attention should be given to the posterior malleolus, as injuries in this region are often missed on standard radiographs[25-28]. CT imaging allows for accurate classification, such as with the Haraguchi system, and has been linked to improved outcomes when the fragment is surgically treated; patients undergoing ORIF demonstrated significantly higher American Orthopaedic Foot and Ankle Score (AOFAS) scores than those managed non-operatively (92.0 vs 82.5, P < 0.001)[30-33].

Moreover, CT arthrography has shown superior cartilage surface delineation in the ankle joint compared to magnetic resonance arthrography, particularly when using high-resolution protocols with one-millimetre slices and two-millimetre reconstructions, vs magnetic resonance imaging performed with 1.5 Tesla scanners and three-millimetre slices[34].

Ultrasound has shown promise as an alternative to radiographs for detecting ankle fractures, but its use remains limited to experienced radiologists due to the need for standardized training[26,27].

MANAGEMENT

Damage control

In open fractures, external fixation offers crucial initial stability while minimizing additional soft tissue trauma, thereby reducing the risk of compartment syndrome, infection, and delayed wound healing[35-37]. In these cases, the Illizarov technique has gained traction, as it permits early weight-bearing and facilitates a transition to definitive care[38].

In closed fractures with substantial swelling or elevated risk of soft tissue complications, external fixation serves as a temporizing measure. This strategy allows stabilization without immediate invasive surgery and is frequently used as a bridging technique prior to definitive internal fixation, striking a balance between early stabilization and soft tissue preservation[35-39].

Timing of definitive ORIF

The optimal timing for ORIF remains a topic of debate. Evidence suggests that performing surgery within six days post-injury yields better functional outcomes, including improved Olerud-Molander Ankle Score (OMAS) and Self-reported Foot and Ankle Score, along with reduced complication rates[40-42]. Delaying surgical intervention beyond six to seven days has been associated with increased risks of wound infection, poorer functional outcomes, and prolonged hospital stays[43-46].

In closed complex fractures, ORIF remains the gold standard. Soft tissue management is critical, especially given the use of larger, more robust fixation hardware in such cases[40-47]. For open fractures, the involvement of an orthoplastic team may allow for advanced wound management techniques. If the arterial blood supply to the limb is intact based on preoperative CT angiography, and the patient has no significant comorbidities, skin flaps may be considered for wound closure[47].

Lateral malleolus

Intramedullary fibular nailing is a viable option for high-risk patients. In Weber B and C fractures, intramedullary nails (145 mm × 3.0 mm and 180 mm × 3.0 mm, respectively) with syndesmotic fixation provide sufficient biomechanical strength through a minimally invasive approach[48,49]. This method reduces surgical trauma, preserves soft tissue integrity, requires shorter operative time, and improves outcomes in osteoporotic bone[50,51]. Studies have reported high union rates, excellent functional outcomes, and low complication rates comparable to traditional ORIF in high-risk populations[52,53]. Dabash et al[48] demonstrated effective fracture reduction and excellent outcomes with no postoperative syndesmotic screw breakage, though compliance with non-weight-bearing protocols was a limitation in some cases.

Minimally invasive locking plates with small fragment screws are another option, particularly in cases with compromised soft tissue[54-56]. Posterolateral antiglide plate fixation improves stability in osteoporotic bone but carries a risk of peroneal tendon irritation, sometimes necessitating hardware removal[55-58]. No significant difference in complication rates has been observed between locking and non-locking neutralization plates[59-63].

Medial malleolus

ORIF is the traditional approach for medial malleolus fractures in trimalleolar injuries. However, emerging evidence supports selective conservative management for anatomically aligned fractures following fibular stabilization, although up to 20 percent radiographic non-union has been reported[64-77]. Surgical options include open and percutaneous screw fixation. The necessity of dual screws has been questioned, especially in osteoporotic bone, where a single fully threaded screw may offer better stability[78,79].

Tension-band wiring is generally reserved for distal avulsion or comminuted fractures (Herscovici types B and C), but complications such as wire migration are common[80]. For vertical fractures (Herscovici type D), antiglide plating is preferred due to its superior biomechanical strength, despite requiring a larger surgical exposure[81-83]. New implants, such as headless or bioabsorbable screws, aim to reduce medial site pain and eliminate the need for removal, but further high-quality research is needed[84,85].

Posterior malleolar fragment

Posterior malleolus fractures, especially when comminuted, present surgical challenges. Historically, fixation was recommended only if the fragment exceeded 25 percent of the tibial articular surface. However, even smaller posterior fragments have been associated with poorer outcomes[86]. Mingo-Robinet et al[87] found better outcomes in fragments involving less than 25 percent of the joint surface, while a systematic review by Odak et al[88] found no correlation between fragment size and clinical results.

The Haraguchi classification guides treatment based on morphology. Type 1 fragments, when fixated, tend to yield favorable outcomes. In contrast, type 2 and 3 configurations, which are more complex, often result in worse prognoses[89].

In cases of talus dislocation or when the fragment involves more than 25 percent of the joint surface, surgical fixation is generally indicated due to the elevated risk of post-traumatic arthritis[86-89]. A modified posterior approach, with a 10-cm incision approximately one cm medial to the Achilles tendon, allows direct visualization and anatomical reduction of up to 91% of the posterior plafond[86-89]. When a medial malleolus fracture is also present, the incision can be extended distally to avoid additional surgical sites.

Although there is no consensus on the optimal fixation method, buttress plates, antiglide plates, and anteroposterior screws remain commonly used. Implant selection should be based on surgeon experience and aimed at achieving stable fixation that permits early weight-bearing[90,91]. However, treating the posterior fragment adds operative time, blood loss, and a higher risk of wound complications[32,92].

Larger posterior fragments, greater than 10 percent of the articular surface, are associated with decreased range of motion in the talocrural and midfoot joints and worse patient-reported outcomes[90-93].

Tibiofibular syndesmosis

Conventional syndesmotic fixation with screws restricts physiological motion of the distal tibiofibular joint and may necessitate later removal. Consequently, alternative techniques are being explored[64,65]. Lehtola et al[66] compared syndesmotic screws and cortical button fixation, reporting similar reduction maintenance at seven-year follow-up with fewer complications in the cortical button group.

Zhu et al[67] introduced a method using high-strength polyester sutures passed through a bone tunnel, avoiding screw removal and promoting faster recovery. In elderly patients, Pearce et al[47] demonstrated that a tibiofibular construct using multiple cortex screws through a posterolateral fibular plate provides stable fixation and facilitates early weight-bearing, which is critical to reducing immobilization-related complications.

Arthroscopic assistance

Arthroscopic-assisted ORIF (AORIF) is increasingly used for acute trimalleolar fractures, particularly in younger, high-demand patients[68,69]. This technique enables direct evaluation and management of associated intra-articular injuries, including chondral damage, deltoid ligament tears, and syndesmotic instability[70-72]. While patients treated with AORIF achieve superior functional outcomes compared to those undergoing traditional ORIF, the cost-effectiveness and potential complications of AORIF require further investigation[73-75].

Deltoid ligament

Ligamentous integrity is as critical as bony alignment in the comprehensive assessment of ankle fractures. In cases of high-grade instability, including syndesmotic or multi-ligamentous injuries, deltoid ligament repair (DLR) may be indicated to restore medial clear space stability[94]. Surgical reinsertion of the deltoid ligament to the medial malleolus or talus is typically performed via a direct open approach. For the superficial deltoid ligament, this is usually 5 mm distal to the tip of the medial malleolus. The deep deltoid ligament is accessed through a longitudinal medial approach, often utilizing micro bone sutures or suture anchors[95,96].

Arthroscopic assistance is increasingly favoured in complex fractures, particularly in highly functional patients such as professional athletes. This approach allows direct visualization of intra-articular lesions and enables early debridement and repair of damaged structures[97]. Although consensus is lacking, growing evidence supports DLR in acute ankle fractures, with studies reporting improved long-term anatomical reduction and reduced pain scores[72,98-102]. As such, DLR remains an important consideration in the surgical management of unstable ankle injuries.

TAILORING SURGICAL APPROACH TO FRACTURE PATTERN AND PATIENT CHARACTERISTICS

The choice of surgical technique must ultimately be individualized, integrating fracture morphology, patient-specific factors, and diagnostic findings. Posterior malleolar fractures with complex or type II/III Haraguchi morphology are best addressed through a direct posterior approach with plate fixation, while smaller, non-displaced fragments may be managed conservatively or with anterior-to-posterior screws[86-90]. In elderly or osteoporotic patients, intramedullary fibular nailing or locking plate fixation may reduce wound complications compared to traditional plating[49]. Younger, high-demand patients may benefit from AORIF, which permits direct assessment of intra-articular lesions[68-70]. CT-based classifications and the condition of the surrounding soft tissues remain key determinants in deciding between immediate fixation, staged management with external fixation, or minimally invasive techniques[25]. Thus, both fracture-specific and patient-specific factors should guide the operative plan, emphasizing the importance of individualized surgical decision-making.

POSTOPERATIVE CARE

Following surgical treatment of trimalleolar ankle fractures, patients should undergo regular follow-up using standardized functional assessment tools. The OMAS is the most widely used functional questionnaire for ankle fractures and has gained global acceptance with multiple language adaptations[103,104]. The AOFAS is also frequently employed to evaluate a broader range of foot and ankle pathologies, while patient-reported outcome measures such as the short form 12 assess patients’ perceived functional health and well-being[105-107].

Early unprotected weight-bearing is increasingly promoted as part of the “get up and walk” approach[108-110]. Dehghan et al[108] demonstrated that this strategy facilitated a faster return to work (mean 4.1 weeks vs 5.7-7.0 weeks with immobilization). Park et al[109] found no significant difference in OMAS scores between weight-bearing and immobilized patients. Keene et al[110] reported that early mobilization may reduce thrombotic risk, though possibly at the expense of higher rates of infection, fixation failure, or reoperation. The mechanisms underlying these complications remain unclear.

Despite advances, many patients continue to experience suboptimal outcomes, including swelling, limited range of motion, and impaired ankle function at around 4.5 months postoperatively[111]. Gait analyses reveal abnormal walking patterns, asymmetric plantar pressure distribution in the hindfoot and forefoot, and altered muscle activity in the tibialis anterior and peroneus longus following fractures[112].

COMPLICATIONS

Common postoperative complications following trimalleolar ankle fractures include myocardial infarction, pneumonia, acute kidney injury, urinary tract infection, pulmonary embolism, sepsis, deep vein thrombosis, and surgical site infection[1-11]. Bohl et al[42] reported that surgical site infections, sepsis, and deep vein thrombosis typically occur within 30 days postoperatively. Additionally, bi- and trimalleolar fractures are associated with an earlier onset of myocardial infarction, urinary tract infection, and sepsis compared to unimalleolar and trimalleolar fractures. Acute kidney injury tends to present later in hospitalized patients than in outpatients, whereas urinary tract infections occur earlier in inpatient settings[1-11,42].

CONTRADICTORY EVIDENCE AND ONGOING DEBATES

Two areas of ankle fracture management remain particularly debated: Fixation of the posterior malleolus and management of syndesmotic screws. For the posterior malleolus, early practice limited fixation to fragments exceeding 25% of the tibial plafond[86]. More recent evidence shows that even smaller fragments may influence joint congruity and outcomes[87-89]. Some systematic reviews support fixation for improved recovery and higher AOFAS scores[30,33,88], while others emphasize increased morbidity, operative time, and wound complications with open fixation[32]. Morphology-based approaches, particularly those guided by CT-based classifications such as Haraguchi, now play a larger role in tailoring management[89-91].

The role of syndesmotic screw management also remains unresolved. Rigid screws restrict physiological tibiofibular motion[64,65], but studies differ on the need for routine removal. Some advocate removal to avoid screw breakage[113,114], whereas others report equivalent or better outcomes when screws are retained or left to break in situ[115]. Alternatives such as cortical buttons[66], high-strength suture constructs[67], and bioabsorbable screws[116] offer dynamic fixation and may reduce the need for secondary procedures.

Together, these debates highlight the complexity of decision-making in trimalleolar fracture care, reinforcing the importance of tailoring treatment to fracture morphology, patient-specific factors, and surgeon expertise. Table 3 consolidates best-practice recommendations across common clinical scenarios, providing a practical framework while acknowledging areas where consensus is lacking.

FUTURE DIRECTIONS

Future research should prioritize large-scale, multicentred randomized controlled trials that compare commonly used surgical techniques across diverse fracture patterns and patient populations. There is also a pressing need for standardized treatment algorithms that integrate advanced imaging-based classification systems with detailed soft tissue assessments to guide surgical decision-making more consistently. Technological advances, such as the application of artificial intelligence for preoperative planning and outcome prediction, represent a promising avenue for improving precision in care. Additionally, broader incorporation of patient-reported outcome measures and real-world clinical data into research and practice could support the development of more patient-centred and personalized treatment strategies.

CONCLUSION

Trimalleolar ankle fractures are complex injuries with high incidence and significant economic impact. Advanced imaging, particularly CT, has improved fracture assessment and surgical planning. Surgery remains the gold standard, with timing and technique critical to reducing complications and costs. Minimally invasive methods for lateral malleolus fractures and novel syndesmosis repair techniques show promise in minimizing reoperations. Management benefits from a multidisciplinary approach guided by Advanced Trauma Life Support principles, with effective communication, leadership, and attention to rehabilitation playing key roles. Despite progress, standardized treatment protocols are still lacking, highlighting the need for further research to improve outcomes and reduce healthcare burdens. Current evidence supports an individualized approach guided by fracture morphology, comorbidities, and soft tissue condition, with early orthoplastic input in complex cases. While formal algorithms continue to evolve, early ORIF and selective use of adjunctive techniques remain key principles. Multicenter studies are needed to inform consistent, high-quality care.