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

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.