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Ankle fracture fixation

101 citationsUpdated Sep 2026

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Overview

The primary goals of ankle fracture treatment are fracture healing and the restoration of normal, pain-free ankle motion and function [7]. While surgical fixation is standard for unstable injuries, residual functional and physical deficits persist in patients five years post-operatively [4]. A structured treatment algorithm is recommended to standardize management and reduce reliance on individual surgeon discretion [1]. Recent research focuses on operative indications for isolated lateral malleolus fractures, posterior malleolus fixation, syndesmosis treatment, and the potential role of fibular nailing [3].

Operative technique selection depends on patient age and soft-tissue status. In adults under 65 years with unstable ankle fractures, fibular nailing yields functional outcomes at one year comparable to open reduction and internal fixation [14]. For elderly patients, plate fixation is usually the treatment of choice [10], though the fibular nail offers accurate reduction with significantly lower soft-tissue complication rates and greater cost-effectiveness [46]. Retrograde tibiofibular intramedullary nailing serves as a useful option when classical internal fixation is contraindicated [43]. In cases where open reduction is contraindicated due to soft-tissue lesions or serious medical problems, closed reduction supplemented by Steinmann-pin fixation has proved effective without redisplacement or pin-tract infections [28]. Arthroscopically assisted reduction of sagittal-plane syndesmosis disruption is indicated in all ankle fractures undergoing open reduction and internal fixation, with no absolute contraindications [2].

Non-operative and adjunctive strategies include immediate weight-bearing as the routine mobilization protocol following fixation [37]. Preoperative vitamin D deficiency correlates with inferior clinical outcomes at a minimum of one year follow-up [17]. A pragmatic multi-centre equivalence randomised controlled trial is designed to compare Close Contact Casting with Open surgical Reduction and Internal Fixation for unstable ankle fractures in patients over 60 years [6]. Current evidence regarding optimal treatment for supination-external rotation ankle fractures remains limited by debatable stability criteria, heterogeneous methodology, small patient numbers, and limited follow-up [42].

Anatomy & Pathophysiology

Bony Anatomy

The ankle joint is a three-bone articulation where the body of the talus meets a confluent tibial area comprising the tibial plafond superiorly and the medial malleolus medially [103]. The fibula bears approximately 1/6th of the load during weight bearing [103]. Because the medial malleolus is shorter and more anterior than the lateral malleolus, the joint axis exhibits 15 degrees of external rotation [103]. The talus is trapezoidal, wider in the anterior body than the posterior body [121]. The posterior malleolus constrains posterior talar translation and anchors the posterior syndesmotic ligaments [121]. In the sagittal plane, the fibula lies posterior to the central tibial axis within the concavity of the distal posterolateral tibia, known as the incisura [121]. The lateral and medial malleoli provide bony restraints to lateral and medial talar translation, respectively [121].

Restoration of normal fibular length is crucial for ankle biomechanics [55]. Fibular shortening results in lateral and valgus subluxation of the talus [56]. On a normal mortise view, the articular margins of the distal fibula and the lateral talar process should be parallel and equal to the tibiotalar joint space [56]. The "ball sign" on the AP view is an unbroken curve connecting the recess in the distal fibular tip and the lateral talar process when the fibula is out to length [56]. Normal radiographic parameters include a talocrural angle of approximately 83 degrees, symmetrical with the contralateral ankle [56], and a medial clear space less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [56]. The tibiofibular clear space (syndesmosis A), measured 10 mm above the joint line, is typically greater than 5 mm [56]. The tibiofibular overlap (syndesmosis B), measured 10 mm above the joint line, is typically less than 5 mm on the AP view and less than 1 mm on the mortise view [56].

Additional normal radiographic benchmarks include a medial clear space between the medial talar shoulder and medial malleolus of less than 5 mm on AP and mortise views [62]. The tibiofibular clear space between the medial border of the distal fibula and the medial incisura typically measures less than 6 mm on AP and mortise views [62]. The medial clear space is typically less than 4 mm [66]. The talocrural angle is 83 (±4) degrees [66]. Talar tilt is typically less than 2 mm [66]. The tibiofibular clear space is less than 6 mm on AP and mortise views, with abnormality of this measurement being most predictive of syndesmotic disruption [66]. Abnormal tibiofibular overlap is more than 6 mm on the AP view and more than 1 mm on the mortise view, whereas normal overlap is less than 10 mm or 42% the width of the fibula [66]. A continuous curve along the lateral talus and tip of the distal fibula is known as the Shenton line or dime sign [66]. The ankle fracture spur sign at the inferomedial tibial metaphysis indicates a hyperflexion variant injury [66].

The fibula lies in the incisura of the lateral tibia, stabilized by the anterior-inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), and the interosseous ligament [103]. The AITFL arises from the tubercle of Chaput on the anterolateral tibia and inserts onto an equivalent prominence on the fibula [103]. The syndesmosis comprises the AITFL, the PITFL, and the interosseous ligament [121]. The PITFL attaches to the lateral aspect of the posterior malleolus [121]. The interosseous ligament is central between the tibia and fibula, with a thinner interosseous membrane coupling the bones proximally [121]. Dorsiflexion widens the mortise as the fibula migrates proximally and externally rotates through the syndesmosis [121]. These syndesmotic ligaments allow joint widening with dorsiflexion into a stable, close-packed position [103]. In elderly patients with ankle fractures, the microarchitecture of distal tibial trabecular bone is abnormal and depleted, resulting in reduced bone stiffness compared with uninjured controls [103].

Ligaments & Soft Tissue

Medial ligamentous support of the tibiotalar joint is provided primarily by the deep deltoid ligament, which limits lateral translation and external rotation of the talus in the mortise [121]. Disruption of the deep deltoid in association with a lateral injury may result in an unstable tibiotalar joint mandating surgical fixation [121]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [111]. An intact deltoid ligament anchors the talus under the tibial plafond even with displacement through a fibula fracture [62]. Medial clear space widening with stress indicates deep deltoid disruption and implies an unstable fracture pattern [66]. In the setting of a medial malleolar fracture, an isolated deltoid ligament injury is rare [60].

The superficial peroneal, sural, and saphenous nerves are at risk in the subcutaneous layer during ankle surgery, where injury may result in a patch of anesthetic or dysesthetic skin [125]. Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk [31].

Pathophysiology & Mechanisms

Ankle fractures are typically low-energy injuries, with the majority occurring due to simple falls or sport [103]. Even open ankle fractures are predominantly low-energy injuries caused by simple falls, with the highest incidence in elderly women [103]. Patients with an AO type C fracture more commonly sustain their injury because of a fall from a height or a motor vehicle accident than patients with AO type A or B fractures [103]. The Lauge-Hansen system is based on cadaver work identifying common fracture patterns based on the position of the foot and direction of force applied at the time of injury [61]. Lauge-Hansen supination-adduction fractures are produced by tension failure of the fibula and axial loading of the medial plafond, resulting in a vertical medial malleolar fracture [61]. Supination-adduction injuries often have impaction of the medial shoulder of the tibial plafond [61]. Medial tibial plafond impaction occurs in up to 50% of supination-adduction cases and must be addressed [66]. The posterior pilon fracture variant is usually associated with a posterior tibiotalar dislocation and has a characteristic posterior malleolar fracture that extends from the PITFL origin laterally to the medial malleolus [61]. This variant produces a double contour of the medial malleolus on the AP radiograph [61]. Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures [15].

The mechanism for fracture-dislocation of the ankle with posterior entrapment of the fibula involves a severe external rotation force applied to the foot, forcing the talus backward out of the mortise and tearing the anterior and posterior syndesmotic ligaments [150]. In posterior entrapment injuries, the fibula is carried posteriorly by the intact lateral collateral ankle ligaments [150]. The proximal fibular fragment in these injuries may be caught on the posterior ridge of the incisura fibularis or fixed in the fracture site of a posterior malleolar fracture [150]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [97]. Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain [132].

The incidence of ankle fractures is increasing sharply in line with the aging demographic of most Western populations [103]. An increase of 319% in the overall annual number of low-energy ankle fractures in elderly patients was reported between 1970 and 2000 [103]. Obesity is a risk factor for sustaining ankle fractures, with obese women over the age of 55 years significantly more likely to sustain an ankle fracture than nonobese women [103]. Obesity predisposes to more severe injury, with patients having an unstable ankle fracture far more likely to be obese (29%) than patients with stable ankle fractures (4%) [103]. Alcohol use is a risk factor for ankle fractures, with 29% of patients in one series found to have consumed alcohol in the 4 hours preceding fracture [103]. Ankle fractures represent 10% of all fractures with an incidence of around 137/10⁵ population per year [103]. The mean age at injury for ankle fractures is 45 years [103]. Both ankle fractures and isolated ankle sprains have a bimodal distribution, with peak incidences in younger men and older women and a 50-year gap between peaks [103]. Bimalleolar and trimalleolar ankle fractures do not have a bimodal distribution but instead a type E distribution with a peak only in elderly women [103].

Ankle fractures are considered the most common physeal fractures of the lower extremity in pediatric patients [58]. Inversion ankle injuries in children typically result in distal fibular physeal fractures, almost exclusively Salter-Harris type I or II [58]. Tillaux fractures are Salter-Harris type III fractures of the anterolateral tibial epiphysis that occur with supination–external rotation injuries [58]. Triplane fractures are Salter-Harris type IV fractures that include an anterolateral fragment of the distal tibial epiphysis in conjunction with a metaphyseal fracture [58]. The most common pattern in the metaphysis for triplane fractures is medial-lateral in the posterior metaphysis [58]. In the epiphysis, an anteroposterior pattern is common for triplane fractures [58]. Growth arrest with angular deformity and/or leg length discrepancy is minimized by reduction within 2 mm of anatomic in pediatric ankle fractures [58]. Medial malleolar Salter-Harris type IV shear ankle fractures have the highest risk of growth arrest [58]. Joint incongruity and late osteoarthritis are risks with distal tibial Salter-Harris type III and IV fractures [58]. Complex regional pain syndrome is relatively common in children following ankle fractures [58].

Diabetic patients with comorbidities such as vasculopathy, neuropathy, or Charcot arthropathy have a higher risk of complications compared with diabetics without comorbidities [33]. Delayed fracture and wound healing, soft-tissue compromise, vasculopathy, and neuropathy need to be considered when formulating a treatment plan for diabetic ankle fractures [33]. Nonoperative treatment of displaced ankle fractures in diabetic patients is associated with up to 21-fold increased odds of complications compared with operative intervention [33]. Wound infection rates of up to 32% have been reported in diabetic patients with ankle fractures [125]. High rates of fixation failure have been reported in elderly patients with ankle fractures [125].

Osteoarthritis of the ankle is most commonly caused by trauma, with 39% of cases in a recent series found to be secondary to ankle fracture [125]. AO/OTA type C fracture patterns, high BMI, dislocation, and increased age are risk factors for the development of post-traumatic osteoarthritis [125]. Cartilage damage is a predictor of posttraumatic osteoarthritis at a mean of almost 13 years follow-up [125]. Worse outcomes for posttraumatic osteoarthritis were found with deeper cartilage lesions and those located on the anterior or lateral talus or the medial malleolus [125]. The most common site of articular cartilage damage following ankle fracture is the talus, followed by the distal tibia and fibula, and finally the medial malleolus [125]. The mean time from ankle fracture to end-stage osteoarthritis is 21 years [125]. Minimal displacement of the talus can lead to increased joint contact pressures and increased risk of posttraumatic arthritis [73]. Restoring the integrity of the lateral malleolus establishes stability of the ankle and prevents late degenerative arthritis [130].

Concomitant intraarticular injuries such as disruption of the syndesmosis, ligament injury, and osteochondral lesions have been reported in up to 80% of patients with ankle fractures [59]. Osteochondral lesions were present in 26% of Weber B fractures, 24% of Weber C fractures, and 20% of isolated medial malleolar fractures [59]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture, and talar dome chondral lesions were present in 43% [59]. All patients with ankle dislocations had a chondral lesion [59]. Patients with complete syndesmosis disruption and instability were more likely to have chondral injury [59]. Patients younger than 30 were less likely to have a chondral injury following ankle fracture [59].

Classification

Lauge-Hansen: This system categorizes ankle fractures based on the mechanism of injury, such as supination external rotation (SER) type IV [36].

AO/OTA: The AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification is used to classify ankle fractures, including types 44-B and 44-C [21].

Weber: The Weber classification is used to classify ankle fractures, including types A, B, and C [21].

Broos: The Broos classification system is a new and easy classification system for ankle fractures [64]. It correlates types of ankle fracture with final results [64].

Haraguchi: The Haraguchi classification is used to classify posterior malleolar fractures, such as type II [78].

Other Considerations: Fractures of the ankle and the distal part of the tibia are treated with the goal of a healed fracture and an ankle that moves and functions normally without pain [7]. Ankle fractures can be classified as open or closed based on injury status [48]. In a study of posterior pilon fractures, 68% were classified as supination external rotation (OTA 44-B), 20% as pronation external rotation, and 12% as pronation abduction (OTA 44-C) [48]. No cases of supination adduction (OTA 44-A) were observed in a study of posterior pilon fractures [48]. The stability-based classification for ankle fracture management and syndesmosis injury is associated with a supination external rotation mechanism of injury [15]. Fracture stability criteria in supination-external rotation ankle fractures are debatable, limiting definitive conclusions regarding optimal treatment [42]. The Maisonneuve-type pronation–external rotation fracture is a specific injury pattern classified in the context of ankle fracture mechanisms [21].

Clinical Presentation

History and Mechanism

Assessment of an ankle fracture requires a detailed history, a thorough physical examination, and radiographic imaging [41]. High-energy mechanisms of injury indicate the likelihood of additional soft tissue complications, compartment syndrome, the presence of the more complex pilon fracture, or other associated injuries [41]. A patient's account of a low-energy twisting injury may reveal little due to the speed of the event, but an appreciation of the energy transfer involved is important [41].

Systemic factors significantly influence prognosis. Diabetes indicates an increased likelihood of wound complications owing to immunologic and vascular impairment [41]. Poorly controlled diabetics are at risk of peripheral neuropathy, which may influence postoperative weight-bearing decisions [41]. A history of smoking, alcohol abuse, and psychiatric illness increases the likelihood of complications [41]. Distal tibiofibular dislocation injury of the ankle with an intact fibula may present with subtle clinical features [70].

Physical Examination

Clinical examination begins with inspection for deformity, bruising, blistering, skin integrity, and color [41]. For bimalleolar ankle fractures in older adults, rigorous analysis starts by evaluating the cutaneous status and viability of the soft tissues upon admission [47].

Palpation of the limb starts at the fibular head and progresses sequentially down the lateral aspect of the leg to the lateral malleolus and the soft tissues anterior and posterior to it before moving medially across the ankle joint to the medial malleolus and its adjacent soft tissue structures [41]. Palpation of the skeleton of the foot excludes commonly associated or missed injuries such as fractures of the metatarsals or lateral talar process, or disruption of the midtarsal (Lisfranc) articulation [41]. Palpation of the Achilles tendon and the Simmonds or Thompson's test exclude rupture of this structure [41].

A distal neurovascular assessment includes assessment of temperature and capillary refill [41]. Skin marking of palpable dorsalis pedis and posterior tibial arterial pulsations at presentation is helpful in later assessment if the condition of the limb deteriorates [41]. Patients with diminished or absent pulses warrant additional workup and potential intervention with a vascular consultation to optimize outcomes [33].

The Ottawa ankle rules provide assistance in determining the need for x-ray by identifying patients presenting with ankle injuries most likely to have sustained a fracture [41]. The Ottawa ankle rules offer a highly sensitive and cost-effective method for identifying patients with ankle fractures [41]. Other authors have reported difficulties in disseminating the Ottawa ankle rules, and their applicability in certain patient groups such as diabetics has been questioned [41].

In diabetic patients, a thorough neurologic and vascular history and examination is required when evaluating ankle fractures [33]. Monofilament examination should be performed on diabetic patients to assess for the presence of sensory neuropathy [33].

Associated Pathology

Osteochondral lesions (OCLs) are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively), with the vast majority located in the talus [35]. In a study of subjects undergoing open ankle fracture fixation, use of arthroscopy before the procedure identified intra-articular pathology in 84.2% of subjects [13]. Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment [74]. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture [27].

Investigations

Clinical Assessment

The initial assessment of a patient with an ankle fracture includes an evaluation of the soft-tissue envelope and neurovascular status [61]. In the absence of abnormal neurologic or vascular signs, or a grossly dislocated tibiotalar joint, radiographs of the ankle before reduction may allow better characterization of the injury [61]. Palpation of the skeleton of the foot will exclude commonly associated or missed injuries such as fractures of the metatarsals or lateral talar process, or disruption of the midtarsal (Lisfranc) articulation [41]. The Ottawa ankle rules provide assistance in determining the need for x-ray by identifying patients presenting with ankle injuries that are most likely to have sustained a fracture [41]. However, the applicability of the Ottawa ankle rules in certain patient groups such as diabetics has been questioned [41].

Plain Radiography

The three standard radiographs for ankle fracture evaluation are an anteroposterior (AP), a lateral, and a mortise projection [56]. A mortise view of the ankle taken in 15 degrees of internal rotation is extremely helpful in assessing the lateral aspect of the ankle, which is often poorly seen on the AP view due to the frustal shape of the talus and consequent overlap of the tibia, fibula, and talus [56]. Interpretation of radiographs follows the sequence ABCS, including an assessment of technical adequacy and alignment, cortical outline and trabecular morphology, and the contour of overlying soft tissues [56].

Specific radiographic measurements guide the assessment of stability and reduction. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [56]. Alternatively, the medial clear space should be less than 4 mm [66]. The tibiofibular clear space (syndesmosis A) 10 mm above the joint line should be greater than 5 mm [56], while other criteria suggest it should be less than 6 mm on AP and mortise views, with abnormality of this measurement being most predictive of syndesmotic disruption [66]. The tibiofibular overlap (syndesmosis B) 10 mm above the joint line should be less than 5 mm on the AP view and less than 1 mm on the mortise view [56], whereas other criteria define it as more than 6 mm on the AP view and more than 1 mm on the mortise view, but less than 10 mm or 42% the width of the fibula [66]. On the mortise view, the articular margins of the distal fibula and the lateral process of the talus should be parallel and equal to the tibiotalar joint space [56]. The "ball sign" is a confirmatory visual cue for fibular length, described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length [56]. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [56]. Medial malleolus displacement should be less than 2 mm [56]. Lateral malleolus displacement should be less than 2 mm shortening, or displacement posteriorly or proximally [56]. Posterior malleolus displacement is defined as a fragment less than 25% of the ankle joint seen on the lateral radiograph and less than 2 mm displaced [56]. Talar tilt should be less than 2 mm [66].

The size of the medial clear space more than doubles depending upon the rotational position of the limb [56], and there is a significant increase in medial clear space with ankle plantarflexion [56]. The accuracy of plain radiographic measurements has been questioned in light of CT studies that have shown that a number of assumptions based on the interpretation of two-dimensional radiographs are not accurate [56]. Consequently, traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [76]. Comparison radiographs of the contralateral limb are particularly useful to identify whether an accurate reduction of fibular length, rotation, and/or the syndesmosis has been obtained [62]. Tenderness of the proximal fibula should be investigated with a full-length radiograph of the leg [56].

External rotation stress or gravity stress radiographs assess for deltoid integrity [66]. Weight-bearing radiographs can simulate the gravity and external rotation stress tests to assess for deltoid integrity [62]. In isolated type B fibular fractures, the weight-bearing radiograph can be of additional value in assessing stability [159]. After reduction of an injury with an ankle fracture spur sign, a CT scan should be obtained to evaluate the articular surface more clearly [66]. If per-operative hard-copy prints are obtained from fluoroscopic images, postoperative radiographs of the ankle are only necessary in exceptional circumstances [156].

Computed Tomography (CT)

A CT scan provides details that may inform the surgical plan, with the specific purpose varying depending on the fracture pattern [62]. For fractures with a posterior malleolar fragment, CT allows evaluation of the orientation of the fracture line, location of the fracture apex, size of the fragment, associated impaction, and presence of medial extension [62]. Impaction of the articular surface can be identified in injuries involving axial load, which is especially prevalent in supination-adduction type injuries where medial shoulder impaction is common [62]. CT can evaluate the syndesmosis, including the shape and depth of the incisura, debris that may block a reduction, and small avulsion fractures of the anterior-inferior tibiofibular ligament or posterior-inferior tibiofibular ligament [62]. Some authors have described obtaining a CT scan of both ankles in the presence of a syndesmosis injury to identify normal anatomy because there is significant variability in the width and congruence of the incisura-fibula relationship in even uninjured ankles [62].

Fractures with a posterior malleolar component or fracture/dislocations are best evaluated with a CT scan to assess for the presence and displacement of articular fragments [66]. The severity of fractures with a posterior malleolar component can be underestimated on plain radiographs compared with appearance on CT scans [66]. Often, after review of CT scans for fractures with a posterior malleolar component, the operative approach is altered [66]. Trimalleolar ankle fractures are considered unstable and generally treated operatively, with computed tomography playing a key role in planning [90]. Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation [157]. Computed tomography is useful for diagnosis of isolated anterior syndesmosis diastasis without fracture in cases of clinical suspicion [161]. CT should be obtained after casting for triplane fractures to confirm that reduction is satisfactory, defined as less than 2 to 3 mm of fracture diastasis and articular step-off [58]. Postreduction CT should show less than 2 to 3 mm of displacement (fracture diastasis or articular step-off) for Salter-Harris type III fractures [58].

Magnetic Resonance Imaging (MRI)

A 2014 study compared MRI with external rotation stress for supination-external rotation injuries and concluded that MRI was unnecessary, displaying a lower interobserver reliability [62]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [142]. All false-negative diagnoses of anterior talofibular ligament injuries were observed at the fibular or talar attachment site [83].

Arthroscopy

Use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects [13]. Arthroscopy can be used to assist with the reduction of fractures of the ankle [59]. A meta-analysis revealed that functional outcomes were better after arthroscopically assisted open reduction and internal fixation than conventional open reduction in patients with ankle fractures [59]. Arthroscopy allows assessment of fracture severity and treatment of concomitant intraarticular injuries, such as disruption of the syndesmosis, ligament injury, and osteochondral lesions [59]. Concomitant injuries have been reported in up to 80% of patients with ankle fractures [59]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture and talar dome chondral lesions in 43% [59]. All patients with dislocations had a chondral lesion [59]. Patients younger than 30 were less likely to have a chondral injury [59]. Arthroscopic evaluation of the joint before fixation of an ankle fracture can detect chondral injuries and latent syndesmosis injuries [59]. Arthroscopy has been found to be more sensitive than MRI and stress radiographs of the syndesmosis in detecting instability [59]. Stress radiographs were inadequate in distinguishing between an intact ligament and a single disrupted ligament, whereas arthroscopy better demonstrated an isolated ligament disruption [59].

A systematic review found fair-quality evidence for use of ankle arthroscopy in detecting intraarticular injuries, but insufficient evidence for improvement of functional outcome, reduction in complication rates, or operative time [59]. Patients with unstable ankle fractures who had concomitant ankle arthroscopy showed no statistically significant improvement but also no increased complications [59]. Average operative time was increased by only 15 minutes when ankle arthroscopy was performed concomitantly with fracture fixation [59]. There is a grade I (incomplete) recommendation for supplementing ankle fracture fixation with arthroscopy [59]. Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries in Maisonneuve fracture complex [160]. The procedure of arthroscopically assisted reduction of sagittal-plane disruption of distal tibiofibular syndesmosis is indicated in all ankle fractures undergoing open reduction and internal fixation with no absolute contraindications [2]. Only a small fracture of the talus is visible via an open approach, which could warrant arthroscopic evaluation [166].

Ultrasound

Ultrasonography may be effective and potentially less painful for the patient in determining whether tibiotalar instability exists in the setting of an isolated fibula fracture [62].

Stress Testing

The gravity and external rotation stress tests take advantage of the fact that an intact deltoid ligament will anchor the talus under the tibial plafond even with displacement through the fibula fracture [62]. A stress test is typically performed to determine whether a supination-external rotation fracture pattern is stable (SER-II) or unstable (SER-IV) [66]. All patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result [165].

Syndesmotic Assessment

When managing an ankle fracture, the syndesmosis must be evaluated, and reduction and stabilization should be performed when instability exists [60]. True instability at the distal tibiofibular joint should be distinguished from isolated medial clear space widening, which can occur with an untreated deltoid ligament injury [60]. It is critical to assess for sagittal (anterior-to-posterior) instability and/or a sagittal plane malreduction of the syndesmosis, which may go unrecognized if not diligently appraised [60]. Isolated assessment of the injured ankle using fluoroscopy is unreliable for determining whether a syndesmosis reduction is accurate [60]. Radiographic comparison of the contralateral extremity, intraoperative or postoperative CT scan, or direct visualization of the confluence of the distal tibia, fibula, and talus are potentially more reliable options for assessing syndesmotic reduction accuracy [60]. A larger study of 87 patients that used comparison postoperative CT scans to measure reduction quality found that syndesmosis malreduction was associated with a poorer clinical outcome [60]. One recent study of 48 patients was unable to detect a difference in functional outcomes based on reduction quality [60]. The distal tibiofibular dislocation injury of the ankle with an intact fibula may present with subtle clinical features [70].

Treatment

Non-Operative

Non-operative management serves as the reference standard for non-displaced or reducible and stable fractures, though it requires considerable expertise and close monitoring [129]. In adult patients with an isolated distal fibula fracture and a medial clear space of ≤6 mm without proven instability, non-operative treatment is safe, preserving good long-term pain and function outcomes while avoiding surgical risks and costs [162]. For injuries of the fibular collateral ligaments, immobilization in plaster for at least six weeks is the only satisfactory non-operative treatment [141]. A pragmatic multi-centre equivalence randomised controlled trial has been designed to compare Close Contact Casting (CCC) with Open surgical Reduction and Internal Fixation (ORIF) for unstable ankle fractures in patients over 60 years [6].

Operative

Indications: Functional recovery following ankle fracture in the elderly is highly satisfactory, confirming the need for surgical reduction to be as anatomical as possible [50]. However, in elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction [81]. Surgical treatment of ankle fractures by podiatrists was associated with higher rates of malunion and nonunion compared with treatment provided by orthopaedic surgeons [16]. ORIF for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors [52].

Surgical Approach / Technique: For lateral malleolus and fibula fractures, the fibular nail allows accurate reduction and secure fixation with a significantly lower rate of soft-tissue complications and is more cost-effective than ORIF [46]. A systematic review suggests that fibular intramedullary nailing (FINF) exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to plate fixation [29]. Retrograde tibiofibular intramedullary nailing (TIMN) appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated [43]. Application of a Ni-Ti arched shape-memory connector (ASC) only fixation is a reliable alternative for managing Type A or B lateral malleolus fractures, leading to fewer soft tissue complications, fewer hardware complaints, and a reduced need for hardware removal [53]. The technique of fixing ankle fracture-dislocations with large posterolateral fragments using tibial buttress plates and fibula nails through a prone posterolateral approach without dissecting the lateral window has been described [120]. A modified posterolateral approach to the ankle reduces the number of incisions required and can be used to manage complex ankle injuries [114].

For posterior malleolus and pilon fractures, the posterolateral surgical approach to the ankle gives adequate access to the posterior malleolus, allowing its anatomical reduction and stable fixation with few complications [96]. A staged treatment approach with early internal fixation for type C3 tibial pilon fractures led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection [9].

For syndesmosis injuries, a novel elastic fixation technique using an encircling and binding technique for tibiofibular syndesmosis stabilization provides firm fixation, combined with earlier return to postoperative exercise and recovery of ankle function [5]. Dynamic fixation demonstrated to be a viable alternative to the static fixation device for distal tibiofibular fixation, with lower reoperation rates and less complications [84]. Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients [25]. There is little published data and no consensus on the fixation method or the need to remove the screw for tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair [145].

For medial malleolus and ligament injuries, the opposing perspective supports a selective, stability-based approach for nondisplaced medial malleolar fractures, citing evidence that nonoperative management of anatomically reduced fractures (≤2 mm displacement) yields equivalent functional outcomes and avoids surgical morbidity such as hardware removal [136]. Bosworth fracture requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction, as non-operative treatment almost always fails [143].

Implant Selection: Elective implant removal rates and complications requiring reoperation were similar between mini fragment and small-fragment fixation of distal fibula fractures [85].

Pain Management: Regional anaesthesia, included in a multimodal analgesia strategy, brings better control of post-operative pain, decreases opioids consumption, and facilitates early mobilisation [158]. The WALANT technique is a safe technique for ankle fracture fixation and has been shown to be useful in foot and ankle surgery, particularly in limited-resource environments [106].

Other Considerations: There is significant variation among orthopaedic surgeons when selecting period of nonweight bearing after fixation of ankle fractures, with both injury pattern and medical comorbidity playing a role in decision of time to keep patient non-weight bearing [139]. A randomised controlled trial is needed to evaluate the effectiveness of additional arthroscopy in complex ankle fractures, as there is currently an absolute lack of studies comparing arthroscopic ORIF to ORIF in this population [11].

Revision: An analysis of fifty ankle fusions revealed sufficient post operative complaints to emphasize the need for careful patient selection for conversion to total ankle arthroplasty [8]. Fourteen years post-procedure, a patient maintained a stable, painless ankle with no additional instability following salvage reconstruction for lateral ankle instability using a tendon allograft [54].

Complications

Infection and Wound Complications

Infection: Bone and joint infection following surgery for ankle and/or hindfoot fractures carries a poor prognosis, with a 15% failure rate involving amputation despite multidisciplinary management [77]. In a prospective randomized comparative study of 60 patients, sepsis occurred in 2 cases (3.33%), all within the plate osteosynthesis group (6.25% of that group), with no cases in the nail osteosynthesis group [104]. In a study of 30 lateral malleolar fracture patients, wound infection occurred in 1 case (3.3%) in the intramedullary nailing group compared to 4 cases (13%) in the plate fixation group [144]. Conversely, in a study comparing intramedullary fixation (IMF) and plate fixation (PF) in operative ankle fractures, no patients in the IMF group experienced deep or superficial infections [100].

Wound Complications: Skin necrosis is a significant risk associated with plate fixation. In a prospective randomized comparative study of 60 patients, skin necrosis occurred in 9 cases (15.00%), all within the plate osteosynthesis group (28.13% of that group), with no cases in the nail osteosynthesis group [104]. ASC only fixation is a reliable alternative for managing Type A or B lateral malleolus fractures, leading to fewer soft tissue complications, fewer hardware complaints, and a reduced need for hardware removal [53]. Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation [170].

Hardware and Fixation Issues

Hardware Failure and Displacement: In a study of 30 lateral malleolar fracture patients, hardware failure occurred in 1 case (3.3%) in the intramedullary nailing group compared to 2 cases (6.5%) in the plate fixation group [144]. In a prospective randomized comparative study of 60 patients, secondary displacement occurred in 2 cases (3.33%), all within the plate osteosynthesis group (6.25% of that group), with no cases in the nail osteosynthesis group [104]. The overall complication rate was significantly lower in the nail osteosynthesis group (7.14%) compared to the plate osteosynthesis group (56.25%) [104]. In a study of 30 lateral malleolar fracture patients, the complication rate was 13.3% in the intramedullary nailing group compared to 32.3% in the plate fixation group [144]. In a study comparing intramedullary fixation (IMF) and plate fixation (PF) in operative ankle fractures, complication rates were comparable at 22% for both groups [100].

Hardware Removal and Salvage: In a study of 997 patients, the incidence and risk factors for removal of internal fixation following surgery for ankle fracture were evaluated [64]. In a study of 12 patients treated with retrograde TIMN, the procedure appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated [43]. In a study of 14 patients, the patient maintained a stable, painless ankle with no additional instability fourteen years post-procedure for salvage reconstruction using a tendon allograft [54].

Nerve Palsy

Sural Nerve Injury: In a study of 26 patients, 9.8% sustained a sural nerve injury with numbness and dysesthesia in the sural distribution, all of which were iatrogenic and occurred postoperatively [94]. Patients who sustained a postoperative sural nerve injury had more ankle fractures secondary to motor vehicle collisions (23.1% versus 9.2%) compared with those without nerve injury [94]. Patients with sural nerve injuries had more associated trimalleolar fractures (69.2% versus 33.9%) and more OTA/AO 44B3 fractures (57.7% versus 25.1%) compared with those without nerve injury [94]. In a study of 30 lateral malleolar fracture patients, nerve injury occurred in 0 cases (0%) in the intramedullary nailing group compared to 3 cases (9.7%) in the plate fixation group [144].

Other Considerations

Algodystrophy and Arthritis: In a prospective randomized comparative study of 60 patients, algodystrophy occurred in 7 cases (11.67%), with 5 cases (15.63%) in the plate osteosynthesis group and 2 cases (7.14%) in the nail osteosynthesis group [104]. In a study of 30 lateral malleolar fracture patients, post-traumatic arthritis occurred in 2 cases (6.7%) in the intramedullary nailing group and 2 cases (6.5%) in the plate fixation group [144].

Patient Demographics and Surgical Parameters: In a study of 30 lateral malleolar fracture patients, the mean age was 41.4 years in the ultrasound group and 39.4 years in the non-ultrasound group [102]. The sex distribution was 5 male/10 female in the ultrasound group and 8 male/7 female in the non-ultrasound group [102]. The hospital stay was 2.6 days in the ultrasound group and 2.8 days in the non-ultrasound group [102]. The operation time was 31.5 minutes in the ultrasound group and 33.9 minutes in the non-ultrasound group [102]. The US device was used for a mean of 40.7 days in the ultrasound group and 39.9 days in the non-US group [102]. The difference in mean age, sex distribution, hospital stay, operation time, and US device usage days between groups was not statistically significant [102].

Surgical Technique and Radiological Outcomes: In a study of 30 lateral malleolar fracture patients, the mean screw length was 40.3 mm in the ultrasound group and 36.3 mm in the non-ultrasound group [102]. The difference in mean screw length between groups was statistically significant (P = 0.019) [102]. Callus formation was observed at the site of the fracture line on the posterior cortex of the fibula in lateral-view radiographs [102]. In a study of 30 lateral malleolar fracture patients, the radiological outcome scores were 3.67 ± 0.60 in the IMN group and 3.71 ± 0.52 in the PF group [144]. The radiological grade was excellent in 22 (73%) of the IMN group and 23 (74%) of the PF group [144]. The radiological grade was good in 6 (20%) of the IMN group and 7 (23%) of the PF group [144]. The radiological grade was fair in 2 (7%) of the IMN group and 1 (3%) of the PF group [144]. The radiological grade was poor in 0 (0%) of both the IMN and PF groups [144].

Functional Scores: In a study of 30 lateral malleolar fracture patients, the AOFAS score at 12 months was 95.6 ± 7.3 in the IMN group and 93.5 ± 10.7 in the PF group [144]. The OMAS score at 12 months was 95.6 ± 7.3 in the IMN group and 93.5 ± 10.7 in the PF group [144]. The AOFAS score at 9 months was 90.5 ± 10.3 in the IMN group and 84.8 ± 12.5 in the PF group [144]. The OMAS score at 9 months was 88.5 ± 9.5 in the IMN group and 84.8 ± 12.5 in the PF group [144]. The AOFAS score at 6 months was 83.5 ± 11.7 in the IMN group and 71.0 ± 12.9 in the PF group [144]. The OMAS score at 6 months was 77.2 ± 9.7 in the IMN group and 71.0 ± 12.9 in the PF group [144]. The AOFAS score at 3 months was 76.9 ± 13.0 in the IMN group and 52.9 ± 13.2 in the PF group [144]. The OMAS score at 3 months was 62.0 ± 12.0 in the IMN group and 52.9 ± 13.2 in the PF group [144]. The AOFAS score at 12 months was 94.3 ± 9.7 in the PF group [144]. The OMAS score at 12 months was 95.3 ± 7.3 in the PF group [144]. The AOFAS score at 9 months was 88.2 ± 14.1 in the PF group [144]. The OMAS score at 9 months was 88.5 ± 9.5 in the PF group [144]. The AOFAS score at 6 months was 77.7 ± 18.7 in the PF group [144]. The OMAS score at 6 months was 77.2 ± 9.7 in the PF group [144]. The AOFAS score at 3 months was 63.2 ± 19.3 in the PF group [144]. The OMAS score at 3 months was 62.0 ± 12.0 in the PF group [144]. The AOFAS score at 12 months was 95.6 ± 7.3 in the IMN group [144]. The OMAS score at 12 months was 95.6 ± 7.3 in the IMN group [144]. The AOFAS score at 9 months was 90.5 ± 10.3 in the IMN group [144]. The OMAS score at 9 months was 88.5 ± 9.5 in the IMN group [144]. The AOFAS score at 6 months was 83.5 ± 11.7 in the IMN group [144]. The OMAS score at 6 months was 77.2 ± 9.7 in the IMN group [144]. The AOFAS score at 3 months was 76.9 ± 13.0 in the IMN group [144]. The OMAS score at 3 months was 62.0 ± 12.0 in the IMN group [144].

Clinical Evaluation and Age-Specific Outcomes: In a study of 118 fractures, the final clinical result was judged on the basis of objective and subjective criteria at the time of evaluation [63]. In a study of 26 patients, 2 patients did not undergo ORIF of fractured malleoli [94]. Higher complication rate after nail compared with plate fixation of ankle fractures in patients aged 60 years or older suggests that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly [10].

Recovery

Light activity (weeks): The evidence does not specify a distinct week range for light activity such as desk work, driving, or light ADLs. However, successful treatment of foot and ankle injuries depends on accurate data, sound clinical judgment, anatomic treatment, and early functional rehabilitation [71].

Full activity (months): The evidence does not specify a distinct month range for full activity, including manual work or sport.

Complete recovery / outcome plateau (months): The evidence does not specify a distinct month range for complete recovery or outcome plateau.

Rehabilitation protocol: These findings support the implementation of immediate weight-bearing as the routine mobilization protocol following ankle fracture fixation [37]. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures [167]. The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications [137]. This novel fixation technique provides firm fixation, combined with earlier return to postoperative exercise and recovery of ankle function [5].

Functional milestones: In adults aged <65 years with unstable ankle fractures, fibular nailing did not differ from ORIF for functional outcome at 1 year [14].

Other Considerations: The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection [9].

Key Evidence

• [L4] The current study demonstrates that a structured treatment algorithm can standardize the management of ankle fractures and make decisions less dependent on the surgeon's discretion. [1] (10.1186/s12891-022-05358-x)
• [Paper] The procedure is indicated in all ankle fractures undergoing open reduction and internal fixation with no absolute contraindications. [2] (10.1016/j.eats.2019.01.014)
• [L5] Recent research topics in ankle fractures include indications for operative treatment of isolated lateral malleolus fractures, the need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. [3] (10.1016/j.injury.2017.08.016)
• [L3] Five years after surgical fixation of an unstable ankle fracture, patients will still have some functional and physical residual effect. [4] (10.1016/j.injury.2007.06.002)
• [L3] This novel fixation technique provides firm fixation, combined with earlier return to postoperative exercise and recovery of ankle function. [5] (10.1186/s13018-023-03579-x)
• [L2] This paper describes the design of a pragmatic multi-centre equivalence randomised controlled trial to compare Close Contact Casting (CCC) with Open surgical Reduction and Internal Fixation (ORIF) for unstable ankle fractures in patients over 60 years. [6] (10.1186/1471-2474-15-79)
• [L5] The goals of treatment for ankle fractures are a healed fracture and an ankle that moves and functions normally without pain. [7] (10.2106/00004623-199611000-00021)
• [L2] The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. [9] (10.1016/j.injury.2024.111385)
• [L1] These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. [10] (10.1302/0301-620x.105b1.bjj-2022-0595.r1)
• [L2] This randomised controlled trial is urgently needed to evaluate the effectiveness of additional arthroscopy in complex ankle fractures, as there is currently an absolute lack of studies comparing AORIF to ORIF in this population. [11] (10.1186/s12891-016-1063-2)
• [L4] The results of this procedure are at least as good as those of other techniques of open reduction and internal fixation of the ankle. [12] (10.2106/jbjs.g.01138)
• [L4] In our study, use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects. [13] (10.1016/j.asmr.2020.08.020)
• [L1] In adults aged <65 years with unstable ankle fractures, fibular nailing did not differ from ORIF for functional outcome at 1 year. [14] (10.2106/jbjs.22.00486)
• [L3] [15] (10.1007/s00402-015-2353-0)
• [L3] Surgical treatment of ankle fractures by podiatrists was associated with higher rates of malunion and nonunion compared with treatment provided by orthopaedic surgeons. [16] (10.5435/jaaos-d-18-00630)
• [L3] In our group of patients with operatively treated ankle fractures, preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up. [17] (10.1007/s00402-015-2376-6)
• [L4] Multiple factors must be considered in deciding whether to address the posterior malleolus fracture surgically, although current indications are unclear. [18] (10.5435/00124635-201402000-00001)
• [L3] Certain patient groups have an increased risk of adverse events following the use of current surgical fixation methods for stabilizing the syndesmosis. [20] (10.1016/j.injury.2019.12.011)
• [L4] [21] (10.1186/s13018-026-06928-8)
• [L4] Long-term functional outcomes at a mean of twenty-one years after pronation-external rotation ankle fractures treated with one or two syndesmotic screws were good to excellent in the great majority of patients despite substantial radiographic evidence of osteoarthritis in one-half of the patients. [25] (10.2106/jbjs.l.00426)
• [L4] Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. [27] (10.1016/j.arthro.2016.08.016)
• [L4] In patients with unstable ankle fractures where open reduction is contraindicated due to soft tissue lesions or serious medical problems, closed reduction supplemented by Steinmann-pin fixation has proved effective with no redisplacement or pin-tract infections observed in this series. [28] (10.2106/00004623-197456030-00012)
• [L1] This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. [29] (10.1186/s13018-024-05032-z)
• [L5] The choice of screw fixation as a treatment for ankle syndesmosis disruption should be carefully evaluated. [30] (10.1007/s00402-006-0131-8)
• [L5] Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. [31] (10.1016/j.injury.2019.10.009)
• [L4] OCLs are frequently seen in patients with ankle fractures when assessed both directly after and at least 12 months after initial trauma (45–47%, respectively), with the vast majority located in the talus. [35] (10.1007/s00167-020-06187-y)
• [L3] [36] (10.1007/s00402-020-03645-7)
• [L1] These findings support the implementation of immediate weight-bearing as the routine mobilization protocol following ankle fracture fixation. [37] (10.2106/jbjs.24.00965)
• [L4] Several literature limitations, including debatable fracture stability criteria, few cohort studies with heterogeneous methodology, small patient numbers, and limited follow-up in some studies, do not allow definitive conclusions regarding the optimal treatment approach. [42] (10.1007/s11999-009-0988-2)
• [L4] Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. [43] (10.1016/j.otsr.2018.03.008)
• [L5] Review of ankle arthroscopy, as an adjunct during ankle fracture open reduction and internal fixation, suggests that the benefits may outweigh the risks, because cartilage injury and other soft-tissue pathology amenable to arthroscopic treatment are common in patients with fracture of the ankle. [44] (10.1016/j.arthro.2015.08.016)
• [L1] The fibular nail allows accurate reduction and secure fixation of ankle fractures, with a significantly lower rate of soft-tissue complications, and is more cost-effective than ORIF. [46] (10.1302/0301-620x.98b9.35837)
• [L5] The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis starting by evaluating the cutaneous status and viability of the soft tissues upon admission. [47] (10.1016/j.otsr.2021.103137)
• [L4] [48] (10.1016/j.injury.2019.10.007)
• [L3] Functional recovery following ankle fracture in the elderly is highly satisfactory, confirming the need for surgical reduction to be as anatomical as possible. [50] (10.1016/j.otsr.2016.03.001)
• [L4] The authors recommend systematic fibular fixation and the use of an orthopaedic table. [51] (10.1016/j.otsr.2010.07.003)
• [L3] ORIF for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors. [52] (10.5435/jaaos-d-25-01391)
• [L3] ASC only fixation is a reliable alternative for managing Type A or B lateral malleolus fractures, leading to fewer soft tissue complications, fewer hardware complaints, and a reduced need for hardware removal. [53] (10.1016/j.injury.2018.10.037)
• [L4] Fourteen years post-procedure, the patient maintained a stable, painless ankle with no additional instability. [54] (10.1097/01.blo.0000092976.12414.b0)
• [L5] Restoration of normal fibular length is crucial to restore the biomechanics of the ankle. [55] (10.1016/j.injury.2018.09.010)
• [L3] [64] (10.1016/j.injury.2016.05.011)
• [L5] The distal tibiofibular dislocation injury of the ankle with an intact fibula may present with subtle clinical features. [70] (10.1016/s0020-1383(01)00193-0)
• [Paper] Successful treatment of foot and ankle injuries depends on accurate data, sound clinical judgment, anatomic treatment, and early functional rehabilitation. [71] (10.1016/s0278-5919(03)00096-6)
• [L4] Acute ankle fractures are commonly concomitant with multiple soft-tissue injuries in which arthroscopy may serve as a method for accurate diagnosis and appropriate treatment. [74] (10.1016/j.arthro.2015.03.043)
• [L3] There is no indication for routine plate osteosynthesis of all posterior malleolus fractures. [75] (10.1016/j.injury.2020.02.109)
• [L2] Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable. [76] (10.1097/01.blo.0000161090.86162.19)
• [L4] The study confirmed the poor prognosis of bone and joint infection following surgery for ankle and/or hindfoot fracture, with a 15% failure rate involving amputation despite multidisciplinary management. [77] (10.1016/j.otsr.2019.06.006)
• [L5] [78] (10.1016/j.injury.2026.113220)
• [L5] In elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction. [81] (10.2106/jbjs.17.01658)
• [L3] In addition, all false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site. [83] (10.1016/j.arthro.2015.02.024)
• [L1] Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. [84] (10.1016/j.injury.2016.09.032)
• [L3] Elective implant removal rates and complications requiring reoperation were similar between mini fragment and small-fragment fixation of distal fibula fractures. [85] (10.1016/j.injury.2024.112014)
• [L4] Trimalleolar ankle fractures are considered unstable and generally treated operatively, with computed tomography playing a key role in planning. [90] (10.1302/2058-5241.6.200138)
• [L3] [94] (10.5435/jaaos-d-23-00577)
• [L4] The posterolateral surgical approach to the ankle gives adequate access to the posterior malleolus, allowing its anatomical reduction and stable fixation with few complications. [96] (10.1302/0301-620x.98b6.36497)
• [L2] Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement. [97] (10.1016/j.jisako.2024.100361)
• [L3] [100] (10.1016/j.injury.2024.111973)
• [L1] [102] (10.1007/s00402-005-0801-y)
• [L2] [104] (10.1016/j.otsr.2014.03.005)
• [L4] The WALANT technique is a safe technique for ankle fracture fixation and has been shown to be useful in foot and ankle surgery, particularly in limited-resource environments. [106] (10.2106/jbjs.20.00196)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [111] (10.2106/00004623-199607000-00006)
• [L4] This reduces the number of incisions required, and is another approach that can be used to manage complex ankle injuries. [114] (10.1016/j.injury.2025.112198)
• [L4] The technique of fixing ankle fracture-dislocations with large posterolateral fragments using tibial buttress plates and fibula nails through a prone posterolateral approach without dissecting the lateral window was described. [120] (10.1016/j.injury.2024.111761)
• [L5] Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring. [129] (10.1016/j.otsr.2018.02.011)
• [L4] Restoring the integrity of the lateral malleolus establishes stability of the ankle and prevents late degenerative arthritis. [130] (10.2106/00004623-197759020-00005)
• [L3] Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain. [132] (10.1177/03635465030310064101)
• [Paper] The opposing perspective supports a selective, stability-based approach, citing evidence that nonoperative management of anatomically reduced fractures (≤2 mm displacement) yields equivalent functional outcomes and avoids surgical morbidity such as hardware removal. [136] (10.1016/j.injury.2026.113369)
• [L4] The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications. [137] (10.1016/j.injury.2016.07.045)
• [L4] There is significant variation among orthopaedic surgeons when selecting period of nonweight bearing after fixation of ankle fractures, with both injury pattern and medical comorbidity playing a role in decision of time to keep patient non-weight bearing. [139] (10.1016/j.injury.2015.03.029)
• [L4] The only satisfactory non-operative treatment is immobilization in plaster for at least six weeks. [141] (10.2106/00004623-196143020-00011)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [142] (10.1007/s00167-019-05581-5)
• [L4] Bosworth fracture requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction, as non-operative treatment almost always fails. [143] (10.1530/eor-23-0050)
• [L1] [144] (10.1016/j.otsr.2019.10.009)
• [L4] However, there is little published data and no consensus on the fixation method or the need to remove the screw. [145] (10.1016/j.otsr.2016.06.015)
• [L4] [150] (10.2106/00004623-197860030-00007)
• [L4] We therefore suggest that if per-operative hard-copy prints are obtained from the fluoroscopic images, postoperative radiographs of the ankle are only necessary in exceptional circumstances. [156] (10.1016/s0020-1383(99)00187-4)
• [L3] Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. [157] (10.1016/j.injury.2018.04.027)
• [L5] The authors conclude that regional anaesthesia, included in a multimodal analgesia strategy, brings better control of post-operative pain, decreases opioids consumption, and facilitates early mobilisation, and they request clarification on the anaesthesia technique used in the referenced study. [158] (10.1016/j.injury.2012.08.019)
• [L4] In isolated type B fibular fractures, the weight-bearing radiograph can be of additional value in assessing the stability. [159] (10.1016/j.injury.2024.111348)
• [L4] Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. [160] (10.1186/s12891-021-04713-8)
• [L4] Isolated anterior syndesmosis diastasis without fracture is a rare entity that can be easily missed in routine X-rays, where computed tomography is useful for diagnosis in cases of clinical suspicion. [161] (10.1007/s00402-007-0296-9)
• [L3] In adult patients with an isolated distal fibula and medial clear space ≤6 mm, without proven instability, these fractures can safely be treated non-operatively, avoiding risks and costs of surgery while preserving good long-term outcome in terms of pain and function. [162] (10.1016/j.injury.2019.10.006)
• [L2] All of the patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result. [165] (10.2106/00004623-200508000-00039)
• [L5] Only a small fracture of the talus is visible via an open approach, which could warrant arthroscopic evaluation. [166] (10.1177/23259671211066856)
• [L1] The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. [167] (10.1302/0301-620x.106b9.bjj-2023-1433.r1)
• [L4] Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. [170] (10.5435/jaaosglobal-d-24-00119)

See Also

• Ankle fracture
• Pilon fracture
• Ankle arthroscopy

References

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[5] A new type of elastic fixation, using an encircling and binding technique, for tibiofibular syndesmosis stabilization: comparison to traditional cortical screw fixation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03579-x

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[14] In Adults Aged <65 Years with Unstable Ankle Fractures, Fibular Nailing Did Not Differ from Open Reduction and Internal Fixation for Functional Outcome at 1 Year. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00486

[15] Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2353-0

[16] Lower Complication Rate Following Ankle Fracture Fixation by Orthopaedic Surgeons Versus Podiatrists. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00630

[17] Perioperative vitamin D levels correlate with clinical outcomes after ankle fracture fixation. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2376-6

[18] Posterior Malleolus Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/00124635-201402000-00001

[20] Factors associated with adverse events after distal tibiofibular syndesmosis fixation. Injury. 2020. DOI: 10.1016/j.injury.2019.12.011

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