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Ankle fracture fixation

104 citationsUpdated Sep 2026

Overview

The primary goals of ankle fracture treatment are achieving a healed fracture and restoring an ankle that moves and functions normally without pain [9]. A structured treatment algorithm standardizes management, reducing reliance on individual surgeon discretion [1]. While recent research focuses on operative indications for isolated lateral malleolus fractures, posterior malleolus fixation, posterolateral approaches, syndesmosis treatment, and fibular nailing [3], five years after surgical fixation of unstable ankle fractures, patients still exhibit functional and physical residual effects [4]. In older adults with bimalleolar fractures, rigorous analysis of cutaneous status and soft-tissue viability upon admission is mandatory [29]. For patients 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].

Surgical fixation strategies vary by patient profile and fracture pattern. Systematic fibular fixation and the use of an orthopaedic table are recommended for distal quarter leg fractures [33]. In adults aged <65 years with unstable ankle fractures, fibular nailing did not differ from open reduction and internal fixation (ORIF) for functional outcome at 1 year [14]. However, 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 in elderly patients [46]. Conversely, plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly [11]. Retrograde tibial intramedullary nailing (TIMN) appears to be a useful option for elderly patients for whom classical internal fixation is contraindicated [44]. Extraperiosteal plating for pronation-abduction ankle fractures yields results at least as good as other ORIF techniques [8].

Adjunctive procedures and preoperative factors influence outcomes. Arthroscopically assisted reduction of sagittal-plane disruption of the distal tibiofibular syndesmosis is indicated in all ankle fractures undergoing ORIF, with no absolute contraindications [2]. Ankle arthroscopy as an adjunct during ORIF may outweigh risks due to common cartilage injury and soft-tissue pathology [45], although a randomised controlled trial is urgently needed to evaluate its effectiveness in complex ankle fractures [12]. The decision to address posterior malleolus fractures surgically involves multiple factors, and there is no indication for routine plate osteosynthesis of all such fractures [19, 71]. Screw fixation for ankle syndesmosis disruption requires careful evaluation, as certain patient groups face increased risks of adverse events [21, 22]. Preoperative vitamin D deficiency correlates with inferior clinical outcomes at a minimum of 1 year follow-up [18]. Immediate weight-bearing is supported as the routine mobilization protocol following fixation [38]. Definitive conclusions regarding optimal treatment for supination-external rotation ankle fractures remain limited by heterogeneous methodology and small patient numbers [43]. An analysis of fifty ankle fusions highlights the need for careful patient selection due to sufficient post-operative complaints [6].

Anatomy & Pathophysiology

Bony Anatomy

The ankle joint functions as a mortise where the body of the talus articulates with a confluent area of the tibia, consisting of the tibial plafond superiorly and the medial malleolus medially [98]. The talus is centered in this mortise, which is created by the tibial plafond and the medial border of the more posterolateral fibula [113]. The talus is shaped like a trapezoid, wider in the anterior body than in the posterior body [113]. Consequently, the talar dome is wider anteriorly than posteriorly, and its lateral circumference is larger than its medial circumference [98]. The lateral articulation of the talus is with the distal fibula [98].

The lateral and medial malleoli provide bony restraints to lateral and medial translation, respectively [113]. The medial malleolus is shorter and more anterior than the lateral malleolus, placing the axis of the joint in 15 degrees of external rotation [98]. The posterior curvature of the tibial plafond, referred to as the posterior malleolus, provides a constraint to posterior translation of the talus [113]. This dorsal projection of the tibia serves to enlarge the confluent articular area [98]. Additionally, the posterior malleolus serves as a ligamentous anchor for the posterior syndesmotic ligaments [113].

The fibula lies posterior to the central axis of the tibia in the sagittal plane within the concavity of the distal posterolateral tibia, known as the incisura [113]. The relationship between the tibia and fibula centers on the syndesmosis, where the fibula lies in the incisura of the lateral aspect of the tibia [98]. The fibula takes 1/6th of the load during weight bearing [98]. Dorsiflexion of the ankle widens the mortise as the fibula migrates proximally and externally rotates through the syndesmosis [113].

Ligaments & Syndesmosis

The tibia and fibula are bound by the distal tibiofibular ligaments, collectively known as the syndesmosis [113]. The syndesmosis comprises the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), and the interosseous ligament [113]. The AITFL arises from a prominence of the anterolateral tibia known as the tubercle of Chaput and inserts onto an equivalent prominence on the fibula [98]. The AITFL attaches to the Chaput tubercle [113]. The PITFL attaches to the lateral aspect of the posterior malleolus [113]. The interosseous ligament is central between the tibia and fibula [113]. Proximal to the syndesmosis, the tibia and fibula are coupled by a thinner layer of tissue known as the interosseous membrane [113]. The fibula is stabilized by the AITFL, PITFL, and interosseous ligament [98]. The syndesmotic ligaments allow widening of the joint with dorsiflexion of the ankle into a stable, close-packed position [98].

Medial ligamentous support of the tibiotalar joint is provided primarily by the deep deltoid ligament [113]. The deep deltoid ligament limits lateral translation and external rotation of the talus in the mortise [113]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [106]. Disruption of the deep deltoid in association with a lateral injury may result in an unstable tibiotalar joint mandating surgical fixation [113].

Pathophysiology & Injury Mechanisms

Ankle fractures represent 10% of all fractures with an incidence of around 137/10⁵ population per year [98]. They are the second most common lower limb fractures after hip fractures [98]. The mean age at injury is 45 years [98]. Ankle injuries have a bimodal distribution with peak incidences in younger men and older women and a 50-year gap between peaks [98]. Bimalleolar and trimalleolar ankle fractures do not have a bimodal distribution but instead a type E distribution with a peak only in elderly women [98]. The incidence of ankle fractures is increasing sharply in line with the aging demographic of most Western populations [98]. The incidence among younger men has appeared to remain static while the increase in elderly women has continued [98]. There has been a reduction in fractures occurring because of severe trauma between 1950 and 1980 and a concomitant increase in the proportion of fractures caused by sporting activity in men [98]. The number of low-energy ankle fractures in elderly patients is predicted to triple by 2030 [98].

Ankle fractures are typically low-energy injuries with the majority occurring due to simple falls or sport [98]. Even open ankle fractures are predominantly low-energy injuries caused by simple falls [98]. Ankle fractures are typically a low-energy mechanism of injury, rotational as opposed to axial load [63]. 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 [98]. 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 [98]. Obesity predisposes to more severe injury, with patients having an unstable ankle fracture being far more likely to be obese than those with stable ankle fractures [98]. Alcohol use appears to be a risk factor for ankle fractures, with 29% of patients in one series found to have consumed alcohol in the 4 hours preceding fracture [98]. Ankle fractures are not associated with systemic low bone mineral density per se [98]. However, the microarchitecture of the trabecular bone in the distal tibia of elderly patients with ankle fractures is abnormal and depleted, and bone stiffness is reduced compared with uninjured controls [98].

Classification Systems: 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 [59]. The Lauge-Hansen classification describes the position of the foot and the injury motion of the foot relative to the leg [63]. Higher stages in the Lauge-Hansen classification include injuries additional to those of stage I [63]. The Orthopaedic Trauma Association and Danis-Weber classifications are based on the location of the fibula fracture and the elements of the ankle joint that are fractured [59]. The Danis-Weber/Orthopaedic Trauma Association (OTA) classification is based on the location of the fibula fracture in relation to the syndesmosis [63]. OTA 44-A fractures are infrasyndesmotic, stable, and rarely require operative intervention [63].

Lauge-Hansen Patterns: Supination-external rotation (SER) is the most common fracture pattern [63]. * SER Stage I: Rupture of the anterior inferior tibiofibular ligament (AITFL) [63]. * SER Stage II: An oblique or spiral fracture of the distal fibula [63]. * SER Stage III: Rupture of the posterior inferior tibiofibular ligament (PITFL) or avulsion fracture of the posterior malleolus [63]. * SER Stage IV: A transverse or oblique fracture of the medial malleolus or deltoid disruption [63].

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 [59]. Supination-adduction injuries often have impaction of the medial shoulder of the tibial plafond [59]. Medial tibial plafond impaction occurs in up to 50% of supination-adduction cases and must be addressed [63]. Supination-adduction injuries are associated with second orthopaedic injuries [63]. 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 [59]. The posterior pilon fracture variant produces a double contour of the medial malleolus on the AP radiograph [59].

Pronation-abduction injuries consist of a large lateral translator force to the foot [63]. * Pronation-abduction Stage I: Rupture of the deltoid ligament or transverse fracture of the medial malleolus [63]. * Pronation-abduction Stage II: Rupture of the AITFL or avulsion of the anterolateral tibia [63]. * Pronation-abduction Stage III: An oblique or spiral fracture of the fibula above the level of the syndesmosis [63]. * Pronation-abduction Stage IV: Rupture of the PITFL or avulsion fracture of the posterior malleolus [63].

Pronation-external rotation follows a distinct sequence: * Stage I: A medial malleolus fracture [63]. * Stage II: An anterior lip of tibial plafond fracture [63]. * Stage III: A fracture of the fibula above the level of the malleolus [63]. * Stage IV: Rupture of the PITFL or avulsion fracture of the posterior malleolus [63].

A newly described fracture pattern with comminution of the posterior malleolus is indicative of more severe articular injury but commonly has a rotational mechanism of injury [63]. This pattern includes fracture of the distal fibula and avulsion fracture of the PITFL, as well as variable patterns of posteromedial plafond and medial malleolus fractures [63]. It is inherently unstable owing to syndesmosis instability [63]. The ankle fracture spur sign at the inferomedial tibial metaphysis is indicative of a hyperflexion variant injury [63]. After reduction of a hyperflexion variant injury, a CT scan should be obtained to evaluate the articular surface more clearly [63].

Biomechanics & Stability: In a simulated supination-external rotation fracture model, the deltoid ligament exerts a restraining influence on external rotation of the talus [106]. In a biomechanical model, isolated posterior malleolus osteotomy and isolated AITFL and interosseous ligament rupture only partially increased fibular motion in dorsiflexion and plantar flexion [109]. The combination of posterior malleolus osteotomy and AITFL and interosseous ligament rupture resulted in an unstable syndesmosis in all planes [109]. Restoration of the integrity of the lateral malleolus establishes stability of the ankle and prevents late degenerative arthritis [122]. Minimal displacement of the talus can lead to increased joint contact pressures and increased risk of posttraumatic arthritis [69]. Tricortical screw fixation significantly increased lateral shift of the talus in a neutral ankle position and constrained motion during plantarflexion compared to the intact ankle [112]. Constrained motion during plantarflexion from tricortical screw fixation can lead to accelerated tibiotalar arthritis [112]. Most studies found distinct characteristics of the incisura fibularis morphology associated with ligamentous ankle lesions, potentially due to lower osseous resistance against tibiofibular displacement [93]. Patients with an ankle sprain were more likely to have a posteriorly positioned fibula, possibly predisposing them to ankle sprain [124].

Posterior Fibular Entrapment: The mechanism for fracture-dislocation of the ankle with posterior entrapment of the fibula involves a severe external rotation force applied to the foot [138]. In this injury, the talus is forced backward out of the mortise, tearing the anterior and posterior syndesmotic ligaments [138]. The fibula is carried posteriorly by the intact lateral collateral ankle ligaments [138]. The inferior part of the fibula breaks off at the posterior tibial border or its shaft remains intact and is dislocated behind the tibia [138]. The proximal fibular fragment may be caught on the posterior ridge of the incisura fibularis or fixed in a fracture site of a posterior malleolar fragment [138]. An articulated external fixator for the ankle joint must be able to follow a 10° fluctuation margin in each plane and must not be based on one axis alone [65].

Clinical Assessment & Indications: Ankle fractures must always be evaluated for deltoid or syndesmosis injury [63]. Tibiotalar instability is the primary indication for surgical management of ankle fractures [119]. Injuries that involve multiple malleoli produce tibiotalar instability and require surgery to restore ankle joint stability [69]. Isolated fibula fractures may be managed nonsurgically if they do not result in ankle joint instability [69]. Restoration of tibiotalar stability and a talus centered under the tibial plafond on both views is required [69]. Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures [15].

The role of the posterior malleolus and syndesmosis continues to be assessed in the literature [66]. Posterior malleolar fracture reduction and fixation have been associated with a reduced need for syndesmosis fixation [66]. The importance of an accurate syndesmosis reduction has been established [66]. Novel methods for avoiding syndesmosis malreduction have been described, including careful tine placement if a clamp is used [66]. The potential benefits of using flexible fixation for the syndesmosis have been described [66]. Careful assessment of the imaging for injury components and soft-tissue injury will guide the surgeon toward the ideal treatment options [66]. Ankle fractures or rotational fractures of the malleoli are common and may result in tibiotalar instability [66]. Ankle fractures typically have good outcomes when appropriately managed either surgically or nonsurgically [66].

The initial assessment of a patient with an ankle fracture includes an evaluation of the soft-tissue envelope and neurovascular status [59]. A carefully documented motor and sensory examination should be performed during initial assessment [59]. 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 [59]. Most rotational ankle fractures, including open fractures, are amenable to early fixation [59]. Some malleoli fractures, especially those that involve axial load, may have similar features to a tibial pilon fracture, including articular impaction that should be addressed at the time of surgery [59]. Thorough assessment of the patient’s imaging and cataloging of the features of their injury are required beyond simple classification [59].

Assessment of an ankle fracture requires a detailed history, a thorough physical examination and radiographic imaging [42]. An appreciation of the energy transfer involved is important as high-energy mechanisms indicate the likelihood of additional soft tissue complications, compartment syndrome, the presence of the more complex pilon fracture, or other associated injuries [42]. Diabetes indicates an increased likelihood of wound complications owing to immunologic and vascular impairment [42]. Poorly controlled diabetics are at risk of peripheral neuropathy, which may influence postoperative weight-bearing decisions [42]. A history of smoking, alcohol abuse, and psychiatric illness increases the likelihood of complications [42].

Clinical examination begins with inspection for deformity, bruising, blistering, skin integrity, and color [42]. A careful 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 [42]. 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 [42]. Palpation of the Achilles tendon and the Simmonds or Thompson's test exclude rupture of this structure [42]. A distal neurovascular assessment includes assessment of temperature and capillary refill [42]. Skin marking of palpable dorsalis pedis and posterior tibial arterial pulsations at presentation will be helpful in later assessment if the condition of the limb deteriorates [42]. The Ottawa ankle rules provide assistance in determining the need for x-ray [42]. The Ottawa ankle rules offer a highly sensitive and cost-effective method of identifying patients presenting with ankle injuries that are most likely to have sustained a fracture [42]. The applicability of the Ottawa ankle rules in certain patient groups such as diabetics has been questioned [42].

Classification

Fractures of the ankle and the distal part of the tibia are classified using systems such as Lauge-Hansen, Weber, and AO/OTA [23].

Lauge-Hansen: This classification categorizes ankle fractures based on the mechanism of injury, including supination external rotation (SER), pronation external rotation, and pronation abduction [47]. In a cohort 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) [47]. The fate of the syndesmosis in type C ankle fractures is the result of a direct laterally applied force to the fibula in combination with an abduction force to the ankle [35].

AO/OTA: The AO/OTA classification is used to define specific fracture patterns, such as Type B fractures of the fibula [128].

Broos and Bisschop: This is a new and easy classification system for ankle fractures [62].

Stability-based: A stability-based classification for ankle fracture management and syndesmosis injury exists for injuries due to a supination external rotation mechanism [15].

Other Considerations: Fracture reduction quality in clinical practice can be evaluated using a Delphi consensus that includes anatomical aspects and fixation evaluation items with lower emphasis on measurements [20]. The Burwell–Chamley imaging scoring system is used to evaluate fracture reduction quality, categorizing results into anatomical reduction, general reduction, and reset error [130]. The reduction of the articular surface in tibial plafond fractures can be classified using a modification of the method of Burwell and Charnley [41]. In the evaluation of distal tibiofibular syndesmosis fixation, malreduction of the articular surface is defined as a step-off or gap of 2 mm or more [40]. Anatomic reduction of the posterior malleolus is defined as any displacement (step or gap) less than 2 mm [47].

Clinical Presentation

History and Mechanism

The mechanism of injury provides critical context for the anticipated severity of the ankle fracture. High-energy mechanisms indicate a likelihood of additional soft tissue complications, compartment syndrome, the presence of more complex pilon fractures, or other associated injuries [42]. Conversely, distal tibiofibular dislocation injuries of the ankle with an intact fibula may present with subtle clinical features [67].

Physical Examination

Palpation of the limb begins 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 [42]. 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 [42]. 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 [42].

In diabetic patients, a thorough neurologic and vascular history and examination is required when evaluating ankle fractures [34]. Monofilament examination should be performed on diabetic patients to assess for the presence of sensory neuropathy [34]. Patients with diminished or absent pulses warrant additional workup and potential intervention with a vascular consultation to optimize outcomes [34].

Diagnostic Criteria and Imaging

The Ottawa ankle rules provide assistance in determining the need for x-ray by identifying patients presenting with ankle injuries who are most likely to have sustained a fracture [42]. These rules offer a highly sensitive and cost-effective method of identifying patients with ankle fractures [42]. 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 [36].

Arthroscopy serves as a useful adjuvant tool to understand the severity and complexity of acute ankle fracture [17]. Use of arthroscopy before open ankle fracture fixation 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 [70].

Special Populations

Diabetic patients with comorbidities, including vasculopathy, neuropathy, and Charcot arthropathy, have a higher risk of complications compared with diabetics without comorbidities [34]. Open reduction and internal fixation (ORIF) for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors [50].

Investigations

Clinical Assessment: The Ottawa ankle rules provide a highly sensitive and cost-effective method for identifying patients with ankle injuries who are most likely to have sustained a fracture [42]. When managing an ankle fracture, the syndesmosis must be evaluated, and reduction and stabilization should be performed when instability exists [58].

Plain radiography: The three standard radiographs for ankle fracture evaluation are an anteroposterior (AP), a lateral, and a mortise projection of the ankle [54]. A mortise view 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 [54]. Interpretation follows the sequence ABCS, including an assessment of technical adequacy and alignment, cortical outline and trabecular morphology, and the contour of overlying soft tissues [54].

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 [54]. The tibiofibular clear space (syndesmosis A) 10 mm above the joint line should be greater than 5 mm [54]. 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 [54]. The articular margins of the distal fibula and the lateral process of the talus on the mortise view should be parallel and equal to the tibiotalar joint space [54]. 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 [54]. The talocrural angle is approximately 83 degrees and symmetrical with the contralateral ankle [54]. Medial malleolus displacement should be less than 2 mm [54]. Lateral malleolus displacement should be less than 2 mm shortening, or displacement posteriorly or proximally [54]. 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 [54].

The size of the medial clear space more than doubles depending upon the rotational position of the limb [54]. There is a significant increase in medial clear space with ankle plantarflexion [54]. 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 [54]. The medial clear space between the medial shoulder of the talar body and medial malleolus typically is less than 5 mm on AP and mortise radiographic views [60]. The tibiofibular clear space between the medial border of the distal fibula and the medial incisura typically measures less than 6 mm on the AP and mortise views [60]. 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 [60].

External rotation stress or gravity stress radiographs assess for deltoid integrity [63]. Medial clear space widening with stress indicates deep deltoid disruption and implies an unstable fracture pattern [63]. Radiographic measurements for syndesmotic issues are made at 10 mm above the plafond [63]. The medial clear space is less than 4 mm [63]. The talocrural angle is 83 (±4) degrees [63]. Talar tilt is less than 2 mm [63]. The tibiofibular clear space is less than 6 mm on AP and mortise views [63]. Abnormality of the tibiofibular clear space is most predictive of syndesmotic disruption [63]. Tibiofibular overlap is more than 6 mm on the AP view and more than 1 mm on the mortise view [63]. Tibiofibular overlap is less than 10 mm or 42% the width of the fibula [63]. A continuous curve along the lateral talus and tip of the distal fibula is known as the Shenton line or dime sign [63]. Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [72]. If per-operative hard-copy prints are obtained from fluoroscopic images, postoperative radiographs of the ankle are only necessary in exceptional circumstances [145].

Computed Tomography (CT): CT is performed for complex fracture patterns and posterior malleolar fractures [63]. 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 [63]. The severity of posterior malleolar fractures on plain radiographs can be underestimated in comparison with appearance on CT scans [63]. After review of CT scans for posterior malleolar fractures, the operative approach is often altered [63]. A CT scan 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 for fractures with a posterior malleolar fragment [60]. Impaction of the articular surface can be identified in injuries involving axial load, which is especially prevalent in supination-adduction type injuries [60]. CT can evaluate the syndesmosis, including 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 [60]. 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 [60]. Computed tomography plays a key role in planning for trimalleolar ankle fractures [80]. 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 [146]. Computed tomography is useful for diagnosis of isolated anterior syndesmosis diastasis without fracture in cases of clinical suspicion [149]. 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 [58]. The axial view of the CT scan can be used to visualize the axis of reduction, planning tine placement, and identify the shape of the incisura [58].

Magnetic Resonance Imaging (MRI): A 2014 study compared MRI with external rotation stress for supination-external rotation (SER) injuries and concluded that MRI was unnecessary, displaying a lower interobserver reliability [60]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [133]. All false-negative diagnoses of anterior talofibular ligament (ATFL) injuries were observed at the fibular or talar attachment site [77].

Arthroscopy: Arthroscopy can be used to assist with the reduction of fractures of the ankle [57]. A meta-analysis by Lee et al. revealed that functional outcomes were better after arthroscopically assisted open reduction and internal fixation than conventional open reduction in patients with ankle fractures [57]. Arthroscopy allows assessment of fracture severity and treatment of concomitant intraarticular injuries, such as disruption of the syndesmosis, ligament injury, and osteochondral lesions [57]. Concomitant injuries have been reported in up to 80% of patients with ankle fractures [57]. Osteochondral lesions were present in 26% of Weber B fractures, 24% of Weber C fractures, and 20% of isolated medial malleolar fractures [57]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture and talar dome chondral lesions in 43% [57]. All patients with dislocations had a chondral lesion [57]. Patients with complete syndesmosis disruption and instability were more likely to have chondral injury [57]. Patients younger than 30 were less likely to have a chondral injury [57]. Arthroscopic evaluation of the joint before fixation of an ankle fracture can detect chondral injuries and latent syndesmosis injuries [57]. Arthroscopy has been found to be more sensitive than MRI and stress radiographs of the syndesmosis in detecting instability [57]. A cadaver study showed that stress radiographs were inadequate in distinguishing between an intact ligament and a single disrupted ligament, whereas arthroscopy better demonstrated an isolated ligament disruption [57]. A systematic review by Gonzalez et al. found fair-quality evidence for use of ankle arthroscopy in detecting intraarticular injuries; however, there was insufficient evidence for improvement of functional outcome, reduction in complication rates, or operative time [57]. Fuchs et al. found no statistically significant improvement in patients with unstable ankle fractures who had concomitant ankle arthroscopy but also found no increased complications [57]. Average operative time was increased by only 15 minutes with concomitant ankle arthroscopy [57]. There is a grade I (incomplete) recommendation for supplementing ankle fracture fixation with arthroscopy [57]. Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries [148]. 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 [154].

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 [60].

Syndesmotic Assessment: After fixation of the bony components of the injury, the syndesmosis may be evaluated under fluoroscopy with either lateral traction on the fibula or external rotation stress [58]. 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 [58]. When evaluating syndesmotic instability, it is critical to assess for sagittal (anterior-to-posterior) instability and/or a sagittal plane malreduction of the syndesmosis [58]. Isolated assessment of the injured ankle using fluoroscopy is unreliable for determining whether a syndesmosis reduction is accurate [58]. Other potentially more reliable options for determining syndesmosis reduction accuracy include radiographic comparison of the contralateral extremity, intraoperative or postoperative CT scan, or direct visualization of the confluence of the distal tibia, fibula, and talus [58]. Off-axis clamping may lead to malreduction of the syndesmosis [58]. A posteriorly placed clamp tine was significantly more likely to lead to malreduction [58]. The thumb reduction technique involves using the surgeon’s thumb to drive the fibula into the incisura in an anteromedial direction and holding the reduction with Kirschner wires while accuracy is assessed [58].

Bioabsorbable screws have higher rates of complications than metal screws, particularly foreign body reactions [58]. Planned screw removal has not been shown to be advantageous compared with retention, and removal may lead to complications, including superficial and deep infection, screw breakage, and recurrent diastasis [58]. In a 2011 study, patients with recurrent diastasis had their screws removed at a mean of 6.7 weeks, whereas in those without diastasis, the screws remained in place for an average of 3 additional weeks [58]. Suture button fixation is a flexible type of fixation meant to guide the fibula into an appropriate position within the incisura, allowing some settling rather than forcing a potential rigid malreduction with a clamp and/or screw [58]. In a study of 97 patients, there was a lower rate of malreduction in the suture button group and less pain at 2-year follow-up compared to screw fixation [58]. In a second study, the screw fixation group had more than twice as many malreductions compared with those of the suture button group (39% versus 15%) and a higher rate of implant removal [58]. Complications with suture button devices have been reported, removal is sometimes still required, the implants can be expensive, and it is unclear if suture button fixation itself is advantageous compared with an accurately reduced syndesmosis managed with screws [58]. Suture-button treatment for acute isolated ankle syndesmotic injuries leads to favorable clinical and radiological outcomes with maintained ankle stability [151]. A new type of elastic fixation, 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 compared to traditional cortical screw fixation [5]. Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk [32]. Isolated anterior syndesmosis diastasis without fracture is a rare entity that can be easily missed in routine X-rays [149].

Classification and Mechanism: The Lauge-Hansen system is based on cadaver work, which identified common fracture patterns based on the position of the foot and direction of force applied at the time of injury [59]. 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 as a contiguous or multifragmentary injury [59]. Lauge-Hansen supination-adduction fractures often have impaction of the medial shoulder of

Treatment

Non-Operative

Non-operative management serves as the reference standard for non-displaced or reducible and stable fractures, though it demands considerable expertise and close monitoring [121]. In adult patients presenting 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 [150]. For injuries involving the fibular collateral ligaments of the ankle, immobilization in plaster for at least six weeks remains the only satisfactory non-operative treatment [132].

Operative

Indications: Surgical intervention is indicated when non-operative criteria are not met. In elderly patients with fragility ankle fractures, nonoperative treatment may be considered, but this decision carries the critical caveat that soft-tissue integrity is of the utmost importance [75]. Conversely, functional recovery following ankle fracture in the elderly is highly satisfactory, confirming the necessity for surgical reduction to be as anatomical as possible [31]. For Bosworth fractures, early reduction of the displaced fibular fragment is required without repeated attempts at closed reduction, as non-operative treatment almost always fails [134].

Surgical Approach / Technique: The choice of fixation technique varies by fracture pattern and patient population. For pronation-abduction ankle fractures, extraperiosteal plating yields results at least as good as other open reduction and internal fixation (ORIF) techniques [8]. Regarding fibular fixation, a systematic review suggests that fibular intramedullary nailing (FINF) exhibits comparable effectiveness to plate fixation in adults [30]. However, evidence in the elderly is mixed: one prospective randomised controlled trial found that fibular nailing allowed accurate reduction with significantly lower soft-tissue complications and greater cost-effectiveness than ORIF [46], while another prospective, randomized controlled trial suggests plate fixation should usually be the treatment of choice for unstable ankle fractures in patients aged 60 years or older, as nail fixation was associated with a higher complication rate [11]. Restoration of normal fibular length is crucial to restore the biomechanics of the ankle [53].

For posterior malleolus fractures, the posterolateral surgical approach provides adequate access for anatomical reduction and stable fixation with few complications [92]. In elderly patients, less invasive techniques such as percutaneously placed anterior-to-posterior screws for posterior malleolar fractures and intramedullary fibular fixation should be considered [75].

Syndesmotic injury management includes arthroscopically assisted reduction of sagittal-plane disruption, which is indicated in all ankle fractures undergoing ORIF with no absolute contraindications [2]. A novel elastic fixation technique using an encircling and binding method provides firm fixation and allows earlier return to postoperative exercise and recovery of ankle function compared to traditional cortical screw fixation [5]. Dynamic fixation of the distal tibiofibular syndesmosis is a viable alternative to static fixation devices, demonstrating lower reoperation rates and fewer complications [79]. 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 [27]. 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 [84].

Implant Selection: Application of a Ni-Ti arched shape-memory connector (ASC) alone 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 [51]. In elderly patients, construct stability is maximized with the use of lateral locking plates, tibia-pro-fibula screws, and bicortical medial malleolar screws [75]. The use of external fixation with hydroxyapatite-coated pins should be considered in the treatment algorithm for fragility ankle fractures in elderly patients [75].

Adjuncts: Soft-tissue preservation in the elderly is optimized with the judicious use of a tourniquet [75]. The WALANT (Wide Awake Local Anesthesia with No Tourniquet) 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 [101].

Pain Management: Regional anaesthesia, included in a multimodal analgesia strategy, brings better control of post-operative pain, decreases opioids consumption, and facilitates early mobilisation [147].

Other Considerations: There is significant variation among orthopaedic surgeons when selecting the period of non-weight bearing after fixation of ankle fractures, with both injury pattern and medical comorbidity playing a role in the decision [129]. Preoperative vitamin D deficiency correlated with inferior clinical outcomes at a minimum of 1 year follow-up in patients with operatively treated ankle fractures [18]. Surgical treatment of ankle fractures by podiatrists was associated with higher rates of malunion and nonunion compared with treatment provided by orthopaedic surgeons [10].

A 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 [12]. Retrograde tibial intramedullary nailing (TIMN) appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated [44]. External fixation with or without internal fixation is an option when salvaging rare injuries like open grade III 'floating ankle' injuries [48]. In elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction [75]. Consultation with medical and nutritional services for the comanagement of elderly patients with a fragility ankle fracture improves outcomes [75].

Revision: An analysis of fifty ankle fusions revealed sufficient post operative complaints to emphasize the need for careful patient selection when converting failed ankle arthrodesis to total ankle arthroplasty [6]. 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 [52].

Complications

Wound, Infection, and Soft Tissue Complications

Infection: Bone and joint infection following surgery for ankle and/or hindfoot fracture carries a poor prognosis, with a 15% failure rate involving amputation despite multidisciplinary management [73]. In a prospective, randomized comparative study of fibular fixation, sepsis occurred in 2 patients (3.33%) overall, with both cases occurring in the plate osteosynthesis group and none in the nail osteosynthesis group [99].

Wound complications: Skin necrosis occurred in 9 patients (15.00%) overall in the same fibular fixation study, with all 9 cases occurring in the plate osteosynthesis group and none in the nail osteosynthesis group [99]. 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]. Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation for distal fibular fractures [158].

Nerve palsy: Twenty-six patients (9.8%) sustained a sural nerve injury with numbness and dysesthesia in the sural distribution, all of which were iatrogenic and occurred postoperatively after surgical management [90]. 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 [90]. 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 sural nerve injury [90].

Hardware and Fixation-Related Complications

Fixation failure: In the prospective, randomized comparative study of fibular fixation, secondary displacement occurred in 2 patients (3.33%) overall, with both cases occurring in the plate osteosynthesis group and none in the nail osteosynthesis group [99]. Non-union (no acquired consolidation) occurred in 2 patients (3.33%) overall, with both cases occurring in the plate osteosynthesis group and none in the nail osteosynthesis group [99].

Syndesmosis fixation: Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications for distal tibiofibular syndesmosis [79]. The meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than four patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant [159].

Other Considerations: Algodystrophy occurred in 7 patients (11.67%) overall in the fibular fixation study, with 5 cases in the plate osteosynthesis group and 2 cases in the nail osteosynthesis group [99]. 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 [51]. Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates [161]. Complications associated with ankle arthrodesis following distal fibula resection may include ankle instability due to resection of ligaments around the ankle, pseudarthrosis, or intraoperative distal tibial fracture [100]. Tibiotalocalcaneal fusion is associated with relatively high complication rates, although proper patient selection and careful graft and fixation planning can minimize postoperative complications [135].

Functional and Long-Term Complications

Recurrent sprain: More than one-third of patients experienced recurrent sprain, and the presence of avulsion fracture was associated with an increased risk of recurrent sprain in children with distal fibula avulsion fractures [81].

Recovery

Light activity (weeks): The EMADE programme demonstrates accelerated recovery compared to traditional six-week cast immobilization for patients undergoing ORIF for Weber B (AO44B) ankle fractures [155]. Minimally-invasive techniques with stable fixation enable early mobilisation, supporting the resumption of light activities such as desk work and light ADLs with minimal complications [78].

Full activity (months): Reconstructive osteotomy for malunited lateral malleolus fractures is beneficial, with twenty of twenty-six patients resuming preinjury activity levels or showing functional improvement [143]. This novel fixation technique provides firm fixation, combined with earlier return to postoperative exercise and recovery of ankle function [5].

Complete recovery / outcome plateau (months): 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 [14]. Fourteen years post-procedure, the patient maintained a stable, painless ankle with no additional instability [52].

Rehabilitation protocol: The EMADE programme facilitates an accelerated recovery trajectory relative to the traditional six-week cast immobilization period [155]. Minimally-invasive approaches and stable fixation protocols are designed to enable early mobilisation [78].

Functional milestones: The minimally-invasive technique and stable fixation yield good functional results [78]. Reconstructive osteotomy results in functional improvement or return to preinjury activity levels in the majority of treated patients [143].

Other Considerations: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care, meaning patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs [141].

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)
• [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. [8] (10.2106/jbjs.g.01138)
• [L5] The goals of treatment for ankle fractures are a healed fracture and an ankle that moves and functions normally without pain. [9] (10.2106/00004623-199611000-00021)
• [L3] Surgical treatment of ankle fractures by podiatrists was associated with higher rates of malunion and nonunion compared with treatment provided by orthopaedic surgeons. [10] (10.5435/jaaos-d-18-00630)
• [L1] These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly. [11] (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. [12] (10.1186/s12891-016-1063-2)
• [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)
• [L4] Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. [17] (10.1016/j.arthro.2016.08.016)
• [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. [18] (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. [19] (10.5435/00124635-201402000-00001)
• [L5] This consensus differs from existing scoring protocols by including a greater number of anatomical aspects and fixation evaluation items with a lower emphasis on measurements, making it more suitable for clinical practice. [20] (10.1007/s00402-010-1198-9)
• [L5] The choice of screw fixation as a treatment for ankle syndesmosis disruption should be carefully evaluated. [21] (10.1007/s00402-006-0131-8)
• [L3] Certain patient groups have an increased risk of adverse events following the use of current surgical fixation methods for stabilizing the syndesmosis. [22] (10.1016/j.injury.2019.12.011)
• [L4] [23] (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. [27] (10.2106/jbjs.l.00426)
• [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)
• [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. [29] (10.1016/j.otsr.2021.103137)
• [L1] This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. [30] (10.1186/s13018-024-05032-z)
• [L3] Functional recovery following ankle fracture in the elderly is highly satisfactory, confirming the need for surgical reduction to be as anatomical as possible. [31] (10.1016/j.otsr.2016.03.001)
• [L5] Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. [32] (10.1016/j.injury.2019.10.009)
• [L4] The authors recommend systematic fibular fixation and the use of an orthopaedic table. [33] (10.1016/j.otsr.2010.07.003)
• [L5] This has not previously been reported and is the result of a direct laterally applied force to the fibula in combination with an abduction force to the ankle. [35] (10.1016/s0020-1383(97)00010-7)
• [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. [36] (10.1007/s00167-020-06187-y)
• [L1] These findings support the implementation of immediate weight-bearing as the routine mobilization protocol following ankle fracture fixation. [38] (10.2106/jbjs.24.00965)
• [L2] [40] (10.1016/j.injury.2016.07.031)
• [L4] [41] (10.2106/00004623-199510000-00004)
• [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. [43] (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. [44] (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. [45] (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)
• [L4] [47] (10.1016/j.injury.2019.10.007)
• [L5] External fixation with or without internal fixation is an option when salvaging rare injuries like open grade III 'floating ankle' injuries. [48] (10.1007/s00402-007-0314-y)
• [L3] ORIF for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors. [50] (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. [51] (10.1016/j.injury.2018.10.037)
• [L4] Fourteen years post-procedure, the patient maintained a stable, painless ankle with no additional instability. [52] (10.1097/01.blo.0000092976.12414.b0)
• [L5] Restoration of normal fibular length is crucial to restore the biomechanics of the ankle. [53] (10.1016/j.injury.2018.09.010)
• [L3] [62] (10.1016/j.injury.2016.05.011)
• [L5] An articulated external fixator for the ankle joint must be able to follow a 10° fluctuation margin in each plane and must not be based on one axis alone. [65] (10.1016/j.injury.2007.09.011)
• [L5] The distal tibiofibular dislocation injury of the ankle with an intact fibula may present with subtle clinical features. [67] (10.1016/s0020-1383(01)00193-0)
• [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. [70] (10.1016/j.arthro.2015.03.043)
• [L3] There is no indication for routine plate osteosynthesis of all posterior malleolus fractures. [71] (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. [72] (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. [73] (10.1016/j.otsr.2019.06.006)
• [L5] [75] (10.2106/jbjs.17.01658)
• [L3] In addition, all false-negative diagnoses of ATFL injuries were observed at the fibular or talar attachment site. [77] (10.1016/j.arthro.2015.02.024)
• [L4] The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications. [78] (10.1016/j.injury.2016.07.045)
• [L1] Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. [79] (10.1016/j.injury.2016.09.032)
• [L4] Trimalleolar ankle fractures are considered unstable and generally treated operatively, with computed tomography playing a key role in planning. [80] (10.1302/2058-5241.6.200138)
• [L3] More than one-third of patients experienced recurrent sprain, and the presence of avulsion fracture was associated with an increased risk of recurrent sprain. [81] (10.1007/s00167-018-5055-7)
• [L4] However, there is little published data and no consensus on the fixation method or the need to remove the screw. [84] (10.1016/j.otsr.2016.06.015)
• [L3] [90] (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. [92] (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. [93] (10.1016/j.jisako.2024.100361)
• [L2] [99] (10.1016/j.otsr.2014.03.005)
• [L4] [100] (10.1530/eor-23-0159)
• [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. [101] (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. [106] (10.2106/00004623-199607000-00006)
• [L5] In this biomechanical model, isolated posterior malleolus osteotomy and isolated anterior inferior tibiobular ligament and interosseous ligament rupture only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of posterior malleolus osteotomy and anterior inferior tibiobular ligament and interosseous ligament rupture resulted in an unstable syndesmosis in all planes. [109] (10.2106/jbjs.23.01088)
• [L5] Tricortical screw fixation significantly increased lateral shift of the talus in a neutral ankle position and constrained motion during plantarflexion compared to the intact ankle, which can lead to accelerated tibiotalar arthritis. [112] (10.1177/2325967118s00159)
• [L5] Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring. [121] (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. [122] (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. [124] (10.1177/03635465030310064101)
• [L5] [128] (10.1186/s13018-017-0537-8)
• [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. [129] (10.1016/j.injury.2015.03.029)
• [L3] [130] (10.1186/s13018-023-03731-7)
• [L4] The only satisfactory non-operative treatment is immobilization in plaster for at least six weeks. [132] (10.2106/00004623-196143020-00011)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [133] (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. [134] (10.1530/eor-23-0050)
• [L5] Although associated with relatively high complication rates, proper patient selection and careful graft and fixation planning can minimize postoperative complications. [135] (10.5435/jaaos-d-14-00102)
• [L4] [138] (10.2106/00004623-197860030-00007)
• [L2] If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care, meaning patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. [141] (10.1186/s12891-018-1946-5)
• [L4] Reconstructive osteotomy for malunited fractures of the lateral malleolus is beneficial, with twenty of twenty-six patients resuming preinjury activity levels or showing functional improvement. [143] (10.2106/00004623-199274060-00018)
• [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. [145] (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. [146] (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. [147] (10.1016/j.injury.2012.08.019)
• [L4] Ankle arthroscopy is a helpful method to guide fibular reduction and to detect and address associated cartilage injuries. [148] (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. [149] (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. [150] (10.1016/j.injury.2019.10.006)
• [L3] Suture-button treatment for acute isolated ankle syndesmotic injuries leads to favorable clinical and radiological outcomes with maintained ankle stability. [151] (10.1186/s12891-024-07849-5)
• [L5] Only a small fracture of the talus is visible via an open approach, which could warrant arthroscopic evaluation. [154] (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. [155] (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. [158] (10.5435/jaaosglobal-d-24-00119)
• [L1] The meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than four patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant. [159] (10.1007/s00167-021-06721-6)
• [L3] Distal fibular fractures managed with locking plates do not have a higher complication rate in comparison to those managed with non-locking plates. [161] (10.1016/j.otsr.2018.03.001)

See Also

• Ankle fracture
• Ankle arthroscopy
• Pilon fracture
• Syndesmotic injury
• Ankle arthrodesis

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

[6] Midterm Outcomes Following Conversion of Failed Ankle Arthrodesis to Total Ankle Arthroplasty, Including Patients With a Deficient Fibula.. 2025.

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[11] Higher complication rate after nail compared with plate fixation of ankle fractures in patients aged 60 years or older: a prospective, randomized controlled trial. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b1.bjj-2022-0595.r1

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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

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