Treatment of Displaced Trimalleolar Ankle Fracture

Initial Assessment and Imaging

• The American College of Radiology recommends obtaining standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) to evaluate fracture displacement, joint alignment, and the extent of posterior malleolar involvement 1, 2
• Weight-bearing radiographs are critical if the patient can tolerate them, as they provide essential information about fracture stability—the most important criterion determining treatment approach 1, 2
• A medial clear space >4 mm indicates instability and confirms the need for surgical intervention 1, 2

Surgical Treatment Algorithm

Postoperative Management

• Early mobilization and physical therapy should begin once adequate healing is confirmed to prevent stiffness and optimize functional outcomes 1
• Premature weight-bearing before adequate healing risks hardware failure, loss of reduction, and nonunion 2
• Serial radiographs are essential to confirm maintenance of reduction and assess healing progression 2

Medial Malleolus Fixation

• Fix the medial malleolus after lateral and posterior malleolar stabilization, as it often reduces anatomically once the fibula is restored to proper length 2
• Standard fixation techniques include screws or tension band wiring depending on fracture pattern and bone quality 2