Clinicians › Ankle

Ankle fracture

143 citationsUpdated Sep 2026

Overview

Ankle fractures are a common injury with a rising prevalence in patients aged 65 years or older, increasing from 22.1% in 2000 to 34.1% in recent data [19]. The number of cases in older populations is expected to continue rising [19], and surgeons are managing an increasing volume of diabetic ankle fractures due to the growing prevalence of diabetes [4]. The primary goals of treatment are a healed fracture and an ankle that moves and functions normally without pain [30]. Achieving good outcomes depends on restoring the stability and alignment of the fractured ankle using either non-operative or operative treatment as appropriate [70]. Current controversy remains in the management of these injuries [2], and future studies must continue to investigate mechanism of injury, fracture patterns, and optimal treatments [1].

Approximately one-third of all ankle fractures are treated surgically [19]. Surgical management is the treatment of choice despite the fragility of the elderly population [17], and open reduction and internal fixation is an effective option for the majority of older patients [80]. Where medically or socially appropriate, surgery should be provided in an outpatient surgical facility to maximize value to the patient and society [139]. Early postoperative weight bearing within approximately 2 weeks after open reduction and internal fixation appears safe in selected patients with anatomically reduced fractures and rigid internal fixation [20], and has not been shown to increase complication or hardware failure rates compared with delayed weight bearing [20]. Unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation [53]. Arthroscopically assisted reduction of sagittal-plane disruption of the distal tibiofibular syndesmosis is indicated in all ankle fractures undergoing open reduction and internal fixation with no absolute contraindications [55].

One year after surgically treated ankle fractures, a majority of patients continue to have symptoms and reported functional limitations [13]. Preoperative vitamin D deficiency correlates with inferior clinical outcomes at a minimum of 1 year follow-up in patients with operatively treated ankle fractures [8]. Higher complication rates are seen in unstable ankle fractures regardless of surgical or nonsurgical treatment [4], though surgical treatment is more likely to result in a stable, functional ankle compared to nonsurgical treatment [4]. Diabetic patients with comorbidities such as vasculopathy, neuropathy, or Charcot arthropathy have a higher risk of complications compared with diabetics without comorbidities [4]. Delayed fracture and wound healing, soft-tissue compromise, vasculopathy, and neuropathy need to be considered when formulating a treatment plan for diabetic ankle fractures [4]. Patients with peripheral artery disease undergoing ankle fracture fixation require long-term risk stratification [5].

Anatomy & Pathophysiology

Bony Anatomy

The ankle joint functions as a mortise, with the body of the talus articulating with a confluent area of the tibia consisting of the tibial plafond superiorly and the medial malleolus medially [114]. The talus is centered in this mortise, which is created by the tibial plafond and the medial border of the more posterolateral fibula [165]. The lateral and medial malleoli provide bony restraints to lateral and medial translation, respectively [165]. The posterior curvature of the tibial plafond, referred to as the posterior malleolus, provides a constraint to posterior translation of the talus and serves as a ligamentous anchor for the posterior syndesmotic ligaments [165]. The talus is shaped like a trapezoid that is wider in the anterior body than in the posterior body [165]. The medial malleolus is shorter and more anterior than the lateral malleolus, placing the axis of the joint in 15 degrees of external rotation [114]. 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 [165]. During weight bearing, the fibula takes one-sixth of the load [114]. Dorsiflexion of the ankle widens the mortise as the fibula migrates proximally and externally rotates through the syndesmosis [165].

Ligaments & Syndesmosis

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 [165]. Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus [142]. The syndesmosis comprises the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), and the interosseous ligament [165]. The AITFL attaches to the Chaput tubercle on the tibia [165]. The PITFL attaches to the lateral aspect of the posterior malleolus [165]. The interosseous ligament is central between the tibia and fibula and is confluent with the interosseous membrane proximally [165]. Distal tibio-fibular instability should be assessed in the sagittal plane, as movements are consistently greater in the sagittal plane than the coronal plane [159].

Pathophysiology & Biomechanics

Disruption of the deep deltoid ligament in association with a lateral injury may result in an unstable tibiotalar joint mandating surgical fixation [165]. Minimal displacement of the talus can lead to increased joint contact pressures and increased risk of posttraumatic arthritis [51]. Fibular shortening, lateral shift, and external rotation, alone and in combination, increase contact pressures in the ankle joint [100]. Tricortical screw fixation of the syndesmosis significantly increases lateral shift of the talus in a neutral ankle position and constrains motion during plantarflexion compared to the intact ankle [157]. Constrained talar motion from tricortical screw fixation can lead to accelerated tibiotalar arthritis [157]. In a biomechanical model, isolated posterior malleolus osteotomy and isolated AITFL and interosseous ligament rupture only partially increased fibular motion, whereas the combination of both resulted in an unstable syndesmosis in all planes [150]. Surgical reduction of a small posterior malleolar fragment with less than 25% ankle joint surface improves pressure distribution but does not affect ankle joint stability [155]. 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 [129].

Epidemiology & Risk Factors

Ankle fractures represent 10% of all fractures with an incidence of around 137/10⁵ population per year [114]. They are the second most common lower limb fractures after hip fractures [114]. The mean age at injury for ankle fractures is 45 years [114]. Ankle injuries have a bimodal distribution with peak incidences in younger men and older women, with a 50-year gap between peaks [114]. Ankle fractures are typically low-energy injuries, with the majority occurring due to simple falls or sport [114]. Open ankle fractures are predominantly low-energy injuries caused by simple falls, with the highest incidence in elderly women [114]. 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 [114]. Bimalleolar and trimalleolar ankle fractures have a type E distribution with a peak only in elderly women [114]. The number of low-energy ankle fractures in elderly patients is predicted to triple by 2030 [114].

Risk Factors: 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 [114]. Obesity predisposes to more severe injury, with patients with an unstable ankle fracture far more likely to be obese (29%) than patients with stable ankle fractures (4%) [114]. Alcohol use is a risk factor for ankle fractures, with 29% of patients in one series having consumed alcohol in the 4 hours preceding fracture [114]. 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 [114]. Men and women differ substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture [16].

Mechanism of Injury: The most common mechanism of injury for all ankle fractures and for each AO/OTA44 fracture group separately was a simple fall [186]. Traffic injuries comprised a substantially higher proportion of high-energy trauma (29.2%) and resulted more frequently in open fractures (4.7%) than other injury mechanisms [186]. Non-unions following fractures of the foot and ankle remain rare and have declined steadily over the past decade [18]. Women between 40 and 59 years of age and young adults constitute groups at elevated risk for non-unions following foot and ankle fractures [18].

Pediatric Pathophysiology

Ankle fractures represent around 5% of all pediatric fractures and 15% to 20% of all physeal injuries [65]. Ankle fractures are considered the most common physeal fractures of the lower extremity in children [65]. Inversion ankle injuries in children typically result in distal fibular physeal fractures, almost exclusively Salter-Harris type I or II [65]. Tillaux fractures are Salter-Harris type III fractures of the anterolateral tibial epiphysis that occur with supination–external rotation injuries [65]. Triplane fractures are Salter-Harris type IV fractures that include an anterolateral fragment of the distal tibial epiphysis in conjunction with a metaphyseal fracture [65]. Growth arrest with angular deformity and/or leg length discrepancy is minimized by reduction within 2 mm of anatomic [65]. Medial malleolar Salter-Harris type IV shear ankle fractures have the highest risk of growth arrest [65]. Joint incongruity and late osteoarthritis are risks with distal tibial Salter-Harris type III and IV fractures [65]. Complex regional pain syndrome is relatively common in children following ankle fractures [65].

Diabetic Pathophysiology

Diabetic patients with ankle fractures present a unique clinical challenge due to increased risk of complications, regardless of surgical or nonsurgical treatment [4]. Diabetic patients with comorbidities such as vasculopathy, neuropathy, and Charcot arthropathy have a higher risk of complications compared with diabetics without comorbidities [4]. Nonoperative treatment of displaced ankle fractures in diabetic patients is associated with up to 21-fold increased odds of complications compared with operative intervention [4]. Wound infection rates of up to 32% have been reported in diabetic patients with ankle fractures [46].

Classification

Weber / Danis-Weber: The Weber classification categorizes fibular fractures into three types based on the fracture height relative to the anterior syndesmosis: type A (distal to the syndesmosis), type B (at the level of the syndesmosis), and type C (proximal to the syndesmosis) [78]. Syndesmotic injury is always present in Weber C fractures, may be present in type B fractures, and is normally absent in type A fractures [78]. This classification predicts outcomes in unimalleolar but not multimalleolar ankle fractures [110]. However, it does not distinguish between stable and unstable type-B fractures [134]. In a study of OTA type A infrasyndesmotic fractures, 8.7% required surgery, compared with 37% of type B transsyndesmotic fractures and 75% of suprasyndesmotic fractures [19]. Of 18 OTA type C fractures treated nonoperatively, 17 (94.4%) were undisplaced C1.1 fractures where manipulation successfully reduced the ankle joint [19]. In an artificial intelligence classification study, type B fractures dominated both internal and external validation datasets, while type A fractures were three times more prevalent in the external validation dataset [126].

Lauge-Hansen: The Lauge-Hansen classification correlates injury mechanisms to specific fracture patterns, identifying four types based on accident circumstances and forces applied to the foot: supination/adduction, supination/eversion, pronation/abduction, and pronation/eversion [78]. Its reliability is limited because the injury mechanism is often speculated by the patient [78]. Gardner et al. reported that the Lauge-Hansen classification predicts only about 50% of ligamentous injuries accurately [134]. Conversely, a study involving MRI and intra-operative findings of 300 ankle fractures found that the Lauge-Hansen classification accurately predicted the ligamentous component of the injury in 94% [134]. The classification does not always predict the extent of the bony component of the injury [134]. For geriatric patients, the Lauge-Hansen classification can guide closed fracture reduction using reversed injury mechanisms to avoid unsuccessful or poor fracture reduction with soft tissue damage [78].

AO/OTA: The AO/OTA classification was applied in a study of 1756 adult ankle fractures in Norrbotten County [14]. Classifications of ankle fractures in the Swedish Fracture Register were concluded to be accurate and valid based on an evaluation of 152 ankle fractures [112]. Detailed description and classification of fractures in a randomized controlled trial protocol for complex ankle fractures were performed using the AO classification system [84].

Gustilo-Anderson: In a study of open ankle fractures, the most frequent grade of injury was IIIa, which accounted for 40% of cases [7]. The mean age of patients with Gustilo-Anderson grade IIIa open ankle fractures was 61 years, which was higher than other grades (p = 0.005) [7]. Grade IIIa open ankle fractures were most prevalent in the elderly, while grade II fractures were more common in patients under the age of 65 [7]. The mean Injury Severity Score (ISS) increased as the Gustilo-Anderson grade increased (PC r = 0.15, p = 0.02), excluding one patient with a grade IIIc fracture [7].

Other Considerations: Ankle fractures can be subdivided into unimalleolar, bimalleolar, or trimalleolar fractures [78]. Trimalleolar fractures with the involvement of a posterior malleolar fragment account for approximately 7% of all ankle fractures [78]. Isolated fibular fractures account for approximately 70% of all fractures involving the ankle [134]. A group of undisplaced, stable ankle fractures has been defined by biomechanical and clinical studies and requires no splintage, protection from weight-bearing, or follow-up radiography [33]. Fractures that are undisplaced at presentation but do not meet criteria for stable fractures may have a higher risk of displacement and may require more active treatment [33]. The DAFC system offers a reliable and comprehensive framework for ankle fracture classification with prognostic insights regarding dislocation and posterior malleolus involvement [109]. A proposed classification system for the posterior tibial fragment based on CT examination may be a useful indication for surgery and defining the most useful approach to these injuries [170].

Clinical Presentation

History and General Assessment

Assessment of an ankle fracture requires a detailed history, a thorough physical examination, and radiographic imaging [35]. High-energy mechanisms of injury indicate the likelihood of additional soft tissue complications, compartment syndrome, complex pilon fractures, or other associated injuries [35]. Comorbidities significantly influence prognosis; diabetes indicates an increased likelihood of wound complications owing to immunologic and vascular impairment [35]. Poorly controlled diabetics are at risk of peripheral neuropathy, which may influence postoperative weight-bearing decisions [35]. A history of smoking, alcohol abuse, and psychiatric illness increases the likelihood of complications [35].

Epidemiologically, more than two thirds of ankle fractures are caused by low-energy trauma [14]. Ankle fractures are more frequent among females [14]. Under the age of 50, ankle fractures are most common in men, while above the age of 50 women become dominant [61]. The most common type of ankle fracture is the B1.1 and A1.2 lateral malleolar fracture according to the Orthopaedic Trauma Association (AO/ATO) classification [61]. Ethnicity and fracture pattern are factors associated with pain at the time of presentation of an acute ankle fracture [91]. Unstable patterns and medial bony injuries contribute significantly to pain at presentation [91]. Radiograph measurement of the degree of ankle swelling at the time of initial emergency department presentation is statistically significant for prediction of an occult ankle fracture [38].

Physical Examination

The initial assessment includes an evaluation of the soft-tissue envelope and neurovascular status [43]. A carefully documented motor and sensory examination should be performed during initial assessment [43]. 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 [43].

Clinical examination begins with inspection for deformity, bruising, blistering, skin integrity, and color [35]. 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 [35]. 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 [35]. Palpation of the Achilles tendon and the Simmonds or Thompson's test exclude rupture of this structure [35].

A distal neurovascular assessment includes assessment of temperature and capillary refill [35]. 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 [35]. 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 [35]. The Ottawa ankle rules offer a highly sensitive and cost-effective method for identifying patients with ankle fractures [35]. The applicability of the Ottawa ankle rules in certain patient groups such as diabetics has been questioned [35].

Imaging and Diagnostic Evaluation

The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield [63]. Recognition of the ankle fracture component in distal tibial spiral shaft fractures is important as it may alter the surgical plan and postoperative management [9]. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture [29]. Ankle arthroscopy may be helpful in clarifying the diagnosis and facilitating treatment in ankle fractures with suspicion of syndesmosis disruption [71]. 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 [62].

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 [11]. Chondral lesions (CL) and/or osteochondral lesions (OCL) appear very frequently after ankle fractures [15].

Special Populations and Comorbidities

A thorough neurologic and vascular history and examination is required when evaluating diabetic patients with ankle fractures [4]. Monofilament examination should be performed on diabetic patients to assess for presence of sensory neuropathy [4]. Patients with diminished or absent pulses warrant additional workup and potential intervention with a vascular consultation to optimize outcomes [4]. Peripheral arterial disease (PAD) is an underdiagnosed condition in geriatric patients presenting with ankle fractures [54].

Treatment of ankle fractures in the elderly remains challenging due to comorbidities, soft tissue trauma, and compliance issues, requiring adapted diagnostic and therapeutic strategies [93]. One year after surgically treated ankle fractures a majority of patients 65 years or older continue to have symptoms and reported functional limitations [13]. Other patient characteristics may play a more prominent role in determining one year mortality following geriatric ankle fractures [27]. Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture [16]. Metabolic syndrome should be treated together with ankle fractures [105].

Open Fractures

The most frequent grade of injury in open ankle fractures was Gustilo Anderson grade IIIa, which accounted for 40% of cases [7]. The mean age of patients with Gustilo Anderson grade IIIa open ankle fractures was 61 years, which was higher than the other grades of injury [7]. The majority of Gustilo Anderson grade IIIa open ankle fracture cases occurred due to a simple fall [7]. Grade IIIa open ankle fractures were most prevalent in the elderly, whilst in patients under the age of 65 grade II fractures were more common [7]. The mean Injury Severity Score (ISS) increased as the Gustilo Anderson grade increased [7]. Patients referred from other units for open ankle fractures underwent more procedures, but similar functional outcomes were achieved, highlighting the importance of managing open ankle fractures in an ortho-plastic specialist centre [64].

Pediatric and Specific Populations

A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries [23]. In dancers, fibular stress fractures are frequently the cause of poor balance and fatigue when initiating a turn [95]. Fibular stress fractures in dancers most often occur in the weight-bearing leg or the ankle of support [95]. Radiographs are frequently negative for fibular stress fractures in dancers, and bone scan may be justified when clinical suspicion exists [95].

Investigations

Clinical Assessment and History: The Ottawa ankle rules provide a highly sensitive and cost-effective method for identifying patients with ankle injuries most likely to have sustained a fracture [35]. Intentional and deliberate evaluation and treatment of diabetic ankle fractures is paramount [4]. Monofilament examination should be performed on diabetic patients to assess for the presence of sensory neuropathy [4]. Peripheral arterial disease is an underdiagnosed condition in geriatric patients presenting with ankle fractures [54].

Plain Radiography: The three standard radiographs for ankle fractures are an anteroposterior (AP), a lateral, and a mortise projection [56]. These views are often sufficient to identify the fracture pattern [82]. Interpretation follows the sequence ABCS, assessing technical adequacy, alignment, cortical outline, trabecular morphology, and soft tissue contour [56]. A mortise view taken in 15 degrees of internal rotation is extremely helpful in assessing the lateral aspect of the ankle [56]. Tenderness of the proximal fibula should be investigated with a full-length radiograph of the leg [56].

Specific radiographic measurements define normal anatomy and reduction criteria. The medial clear space should be less than 5 mm and no more than 2 mm greater than the tibiotalar clear space [56]. This space is typically less than 5 mm on AP and mortise views [77] and less than 4 mm in normal ankle radiographs [82]. The tibiofibular clear space (syndesmosis A) 10 mm above the joint line should be greater than 5 mm [56], typically measuring less than 6 mm on AP and mortise views [77, 82]. 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]. In abnormal cases, tibiofibular overlap is more than 6 mm on the AP view and more than 1 mm on the mortise view [82]. In normal cases, tibiofibular overlap is less than 10 mm or 42% the width of the fibula [82]. Radiographic measurements for syndesmotic issues are made at 10 mm above the plafond [82].

Additional normal parameters include a talocrural angle of approximately 83 degrees, symmetrical with the contralateral ankle [56], and 83 (±4) degrees in normal radiographs [82]. Talar tilt is less than 2 mm in normal ankle radiographs [82]. 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 [56]. A continuous curve along the lateral talus and tip of the distal fibula is known as the Shenton line or dime sign [82]. The "ball sign" is a confirmatory visual cue for fibular length, described as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus [56].

Displacement limits for reduction are strict. 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 must be less than 25% of the ankle joint seen on the lateral radiograph and less than 2 mm displaced [56]. Abnormality of the tibiofibular clear space is most predictive of syndesmotic disruption [82]. The ankle fracture spur sign at the inferomedial tibial metaphysis is indicative of a hyperflexion variant injury [82]. After reduction of an injury with an ankle fracture spur sign, a CT scan should be obtained to evaluate the articular surface more clearly [82]. 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 [77].

Routine radiographs at the early outpatient visit are not supported in ankle fracture patients without clinical signs of a complication [10]. Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up [180]. If per-operative hard-copy prints are obtained from fluoroscopic images, postoperative radiographs of the ankle are only necessary in exceptional circumstances [195]. The radiological result is not associated with a good functional outcome [22].

Stress Testing and Stability Assessment: External rotation stress or gravity stress radiographs assess for deltoid integrity [82]. These 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 [77]. Weight-bearing radiographs can simulate the gravity and external rotation stress tests [77]. Medial clear space widening with stress indicates deep deltoid ligament disruption and implies an unstable fracture pattern [82]. External rotation may be helpful to indicate evidence of medial ankle instability [82]. Ultrasonography may be effective and potentially less painful for the patient in assessing deltoid integrity [77].

Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable [88]. After fixation of the bony components of an ankle injury, the syndesmosis may be evaluated under fluoroscopy with either lateral traction on the fibula or external rotation stress [75]. If the tibiofibular clear space widens compared with the normal ankle during stress testing, there is likely some degree of syndesmosis injury [75]. If only the medial clear space widens during stress testing, the deltoid ligament is injured [75]. 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 [75]. When evaluating syndesmotic instability, it is critical to assess for sagittal (anterior-to-posterior) instability and/or a sagittal plane malreduction of the syndesmosis [75]. In the setting of a medial malleolar fracture, an isolated deltoid ligament injury is rare [75]. Patients with noncomminuted lateral malleolar fractures could be diagnosed with a stable ankle mortise without further stress testing when the fracture line widths were <2 mm on lateral radiographs [187].

CT: CT is performed for complex fracture patterns and posterior malleolar fractures [82]. 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 [82]. The severity of posterior malleolar fractures on plain radiographs can be underestimated in comparison with appearance on CT scans [82]. Often, after review of CT scans for posterior malleolar fractures, the operative approach is altered [82]. A CT scan provides details that may inform the surgical plan, including the orientation of the fracture line, location of the fracture apex, size of the fragment, associated impaction, and presence of medial extension for posterior malleolar fragments [77]. Impaction of the articular surface can be identified in injuries involving axial load, which is especially prevalent in supination-adduction type injuries [77].

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 [77]. Some authors have described obtaining a CT scan of both ankles in the presence of a syndesmosis injury to identify normal anatomy [77]. Computed tomography plays a key role in planning for trimalleolar ankle fractures [189]. Performing CT assessment in all patients suspected to have or diagnosed with posterior malleolar fractures on standard radiographs will increase the number of reported cases of posterior pilon variant fractures and enable more accurate surgical planning [190]. A protocol including computed tomography of the ankle may detect more injuries in patients with spiral distal tibial fractures [183]. CT should be obtained after casting for triplane fractures in pediatric patients to confirm that reduction is satisfactory [65]. Salter-Harris type III pediatric ankle fractures require postreduction CT to show less than 2 to 3 mm of displacement (fracture diastasis or articular step-off) for closed treatment [65].

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 [77]. On the basis of a 2014 study, MR imaging is not recommended as an important factor in choosing between operative and nonoperative treatment of an SER-type ankle fracture [87]. Conventional radiography and MRI are not sufficient in assessing syndesmotic disruption, and magnetic resonance arthrography (MRA) can make an important contribution to diagnosis in ankle fractures [111]. MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time [182]. MRI is a necessary component of the work-up of every painful ankle to avoid long-term sequelae, misdiagnosis, and managed patient expectations [184]. MRI can show severe bone injuries that are not visible radiographically in ice hockey players [185].

Arthroscopy: Arthroscopy allows assessment of fracture severity and treatment of concomitant intraarticular injuries, such as disruption of the syndesmosis, ligament injury, and osteochondral lesions [66]. Concomitant injuries have been reported in up to 80% of patients with ankle fractures [66]. Osteochondral lesions were present in 26% of Weber B fractures, 24% of Weber C fractures, and 20% of isolated medial malleolar fractures [66]. Chondral lesions were identified in 78% of 116 patients with acute ankle fracture and talar dome chondral lesions in 43% [66]. All patients with dislocations had a chondral lesion, and patients with complete syndesmosis disruption and instability were more likely to have chondral injury [66]. Patients younger than 30 were less likely to have a chondral injury [66].

Arthroscopic evaluation of the joint before fixation of an ankle fracture can detect chondral injuries and latent syndesmosis injuries [66]. Arthroscopy has been found to be more sensitive than MRI and stress radiographs of the syndesmosis in detecting instability [66]. 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 [66]. In a systematic review, 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 [66]. 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 [66]. Average operative time was increased by only 15 minutes when ankle arthroscopy was added to fracture fixation [66]. There is a grade I (incomplete) recommendation for supplementing ankle fracture fixation with arthroscopy [66]. In a study of acute ankle fractures, use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects [191]. In ankle fractures with suspicion of syndesmosis disruption, ankle arthroscopy may be helpful in clarifying the diagnosis and facilitating treatment [71].

Other Considerations: An analysis of the imaging features of tibial shaft fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options [37]. A Delphi consensus was reached on specific imaging techniques, anatomical aspects, and fracture reduction parameters for evaluating wrist and ankle fractures [86].

Treatment

General Principles and Goals

Management of ankle fractures is dictated by stability; stable fractures are managed nonsurgically, while unstable fractures require open reduction and internal fixation (ORIF) [74]. Injuries involving multiple malleoli typically produce tibiotalar instability and necessitate surgical intervention to restore joint stability [51]. Isolated fibula fractures may be managed nonsurgically if they do not result in ankle joint instability [51]. Restoration of tibiotalar stability, with the talus centered under the tibial plafond on both views, is critical because minimal displacement of the talus can lead to increased joint contact pressures and a higher risk of posttraumatic arthritis [51]. A structured treatment algorithm can standardize management and reduce reliance on surgeon discretion [45]. In resource-limited settings, such as Malawi, adult ankle fractures are predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery, driven by resource limitations, knowledge deficits, and lack of treatment standardization [6].

Non-Operative

Stable ankle fractures form a clinically benign group amenable to functional treatment [12, 128]. A specific subset of undisplaced, stable fractures requires no splintage, protection from weight-bearing, or follow-up radiography, though ankle braces are often used for comfort [33]. Radiographically stable Weber B fractures achieve bony union in 99.4% of cases using a standardized vertical fibular cast (VFC) protocol that involves early full weight bearing in a supportive orthotic from first presentation [123]. While many surgeons restrict weight bearing for six weeks after cast application, evidence supporting this regime is lacking, and significant variation exists among orthopedic surgeons regarding non-weight-bearing duration [19]. For stable type B ankle fractures, treatment with a brace is a safe and more comfortable option compared to casting, with no significant differences in outcomes at one year [118]. In older patients with unstable ankle fractures, close contact casting yields functional outcomes equivalent to surgery, although 19% of patients required secondary surgical treatment [19]. Non-operative management of the medial malleolar component in unstable ankle fractures treated with a fibular nail may reduce post-operative complications without compromising patient-reported outcomes [116]. However, non-operative management in diabetic patients results in higher complication rates compared to operative management [94].

Operative

Indications: In the absence of severe systemic comorbidities, outcomes after ORIF of malleolar fractures are nearly identical for patients above and below 60 years of age, whereas nonoperative treatment of unstable fractures leads to significantly inferior outcomes [166]. The reduction and fixation strategy depends on the fracture pattern, bone quality, and soft tissue condition [51].

Surgical Approach / Technique: The fibula fracture is commonly addressed first through direct reduction. For oblique fractures, a lag screw is placed followed by neutralization or antiglide plating; compression plating is used for transverse fractures [51]. Bridge plating paired with indirect reduction techniques is used for comminution, aiming to restore fibular length, alignment, and rotation [51]. Intramedullary screw or rod fixation of the fibula is an option, particularly useful when soft tissues are traumatized or wound complication risk is high from a more open approach [51]. Most medial malleolar fractures are amenable to direct reduction and fixation with one or two fully threaded solid or cannulated screws [51]. A recent randomized controlled trial demonstrated no difference in patient-reported outcomes between one and two screws for medial malleolar fractures [51]. Buttress plating is recommended for vertical medial malleolar fractures seen in supination-adduction injuries [51]. If a medial malleolar fracture is absent, deltoid repair has been advocated after fibular fixation if persistent tibiotalar instability exists, though indications are not well established [51]. Vertical transarticular-pin fixation provides efficient stabilization for unstable ankle fractures but should be limited to emergencies or cases where conventional methods are inadvisable [73]. Retrograde tibial intramedullary nailing (TIMN) is a useful option for elderly patients for whom classical internal fixation is contraindicated [115].

Implant Selection: Locking plates can be used in patients with poor bone quality or neuropathy [51]. The fibular intramedullary nail exhibits comparable effectiveness to plate fixation in adults [72]. ARIF and ORIF are comparable in providing pain relief and improving function [117].

Adjuncts: The authors do not recommend using a tourniquet for osteosynthesis of ankle fractures [141]. Spinal anesthesia should be offered to patients undergoing operative fixation unless there is a specific contraindication [53].

Setting of Care: Outpatient management of isolated ankle fractures is safe and offers substantial economic benefits [127].

Other Considerations: Treatment of bimalleolar ankle fractures in older adults requires rigorous analysis starting with evaluation of cutaneous status and soft tissue viability upon admission [42].

Posterior Malleolus and Syndesmosis

Surgical management of the posterior malleolus has been controversial, with historical indications varying primarily based on fragment size [49]. The literature suggests that even small posterior malleolar fractures can affect patient outcomes [49]. Reduction and fixation of a displaced posterior malleolus fracture offers benefits including constraint to posterior tibiotalar instability and restoration of tibial plafond articular congruity [49]. Stabilization of the posterior inferior tibiofibular ligament (PITFL) attachment improves syndesmotic stability, and restoration of the posterior tibial plafond restores bony constraint of the posterior incisura [49]. One recent study found that posterior malleolus fixation significantly reduced the likelihood of requiring syndesmosis fixation [49]. Conversely, another study found that malreduction of the posterior malleolus was more likely to result in syndesmotic malreduction [49]. In many cases, anatomic reduction of the posterior malleolus indirectly aids in restoring fibular length and rotation in complex fibula fractures due to PITFL attachments [49]. If surgical management is chosen, reduction may be accomplished indirectly via anatomic fibula reduction, percutaneously, or directly via a posterolateral or posteromedial approach [49]. If the fibula is reduced first, implants must be placed to avoid blocking radiographic assessment of the posterior malleolus [49]. Fixation options include anterior-to-posterior lag or position screws, posterior-to-anterior screws, or posterior buttress plating [49]. Buttress plating is biomechanically favorable, though it is unclear if this increased construct strength is clinically meaningful [49]. Direct reduction from a posterior approach has been linked to improved patient function compared with percutaneous reduction and anterior-to-posterior screws [49]. Multiple factors must be considered when deciding whether to address the posterior malleolus surgically, although current indications remain unclear [76]. The role of the posterior malleolus and syndesmosis continues to be assessed in the literature [47]. Posterior malleolar fracture reduction and fixation have been associated with a reduced need for syndesmosis fixation [47]. The importance of accurate syndesmosis reduction is established, and novel methods for avoiding malreduction include careful tine placement when a clamp is used [47]. Potential benefits of using flexible fixation for the syndesmosis have been described [47]. Arthroscopy can be performed for evaluation and management of syndesmotic injury and for persistent pain following definitive treatment [32]. Arthroscopically assisted reduction of sagittal-plane disruption of the distal tibiofibular syndesmosis is indicated in all ankle fractures undergoing ORIF with no absolute contraindications [55]. Suture button fixation reduces rates of malreduction but generally increases cost and does not eliminate complications or the need for implant removal [171]. Comparison radiographs of the contralateral extremity, CT scan, or direct visualization are options for assessing syndesmosis reduction accuracy, and malreduction is associated with poorer clinical outcomes [171].

Weight-Bearing and Rehabilitation

Early postoperative weight bearing initiated within approximately two weeks after ORIF appears safe in selected patients with anatomically reduced fractures and rigid internal fixation, without increasing complication or hardware failure rates compared with delayed weight bearing [20]. Early weight-bearing following ankle fracture surgery results in superior functional outcomes and equivalent safety compared to delayed protocols [41]. Early weight-bearing was noninferior to delayed weight-bearing and is likely cost-effective [89]. Early weightbearing after operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months [140]. Early, rather than late, weight-bearing and range-of-motion exercise improved early function but did not improve time to return to work after surgical fixation of unstable ankle fractures [40]. Recovery of normal ankle dorsiflexion flexibility typically takes longer than the initial period of immobilization [81]. Results from the joint mobilisation trial will contribute to an evidence-based approach for rehabilitation after ankle fracture [135].

In elderly patients, postoperative rehabilitation goals must be weighed against diminished healing potential, particularly with concomitant diabetes [133]. Common protocols include early range-of-motion exercises with gradual weight-bearing advancement [133]. Weight-bearing is often protected for a longer duration in elderly patients compared with younger patients [133]. At one institution, elderly patients are managed with immobilization in a splint for two weeks, followed by four to six weeks of support in a removable brace, and then gradual progression to full weight-bearing [133]. There are no studies to date analyzing the morbidity of prolonged immobilization in the elderly after ankle fracture repair [133]. Longer immobilization periods and casting may be required for delayed healing or in patients with cognitive dysfunction who cannot follow postoperative instructions [133]. For diabetic ankle fractures, prolonged non-weight bearing followed by rehabilitation are the final steps in management [131].

Special Populations and Comorbidities

Diabetic Patients: Treatment of diabetic ankle fractures is dictated by fracture pattern, stability, and patient comorbidities [4]. Isolated, stable, nondisplaced diabetic ankle fractures can be treated by closed means, but close follow-up with radiographic and clinical evaluation is essential [4]. Any displacement or loss of reduction in diabetic ankle fractures should be treated with surgical stabilization [4]. Higher complication rates are seen in unstable ankle fractures regardless of treatment modality; however, surgical treatment is more likely to result in a stable, functional ankle [4]. In patients without associated diabetic comorbidities, standard ankle fracture fixation principles can be used [4]. When comorbidities are present, additional supplemental fixation (e.g., multiple syndesmotic screws, bicortical medial malleolar screws, transarticular fixation, or supplemental external fixation devices) can be added to surgical constructs to enhance stability [4]. Immediate surgical fixation of closed ankle fractures in patients with preoperatively neglected type 2 diabetes showed similar ankle scores to non-diabetic controls and did not worsen the final prognosis [50]. Operative treatment in patients with complicated diabetes mellitus is associated with significant complications, including significantly increased risk of unplanned readmission, unplanned reoperation, and mortality [163]. Complications in diabetic patients have been reported to be as high as 43% compared with 15.5% in patients without diabetes [163]. Nonoperative treatment is recommended for malleolar fractures in older diabetic patients with low functional demands [163]. If surgical treatment is indicated in diabetic patients, it should not be delayed or avoided simply because the patient is diabetic [163]. Inadequate immobilization may lead to rapidly developing neuropathy in diabetic patients [163]. If the ankle fracture is nondisplaced or minimally displaced with a stable configuration, closed management with prolonged casting is an acceptable alternative for diabetic patients, but only with close supervision [163]. If the fracture is displaced and considerable manipulation is necessary to reduce it or molding is required to maintain the reduction, an open approach with internal fixation is recommended for diabetic patients [163]. Regardless of the method of treatment, prolonged immobilization often is necessary to prevent the development of neuropathic complications in diabetic patients [163]. In certain patients deemed at increased risk for fixation failure, the fixation strategy may be modified to obtain rigid fixation, including bicortical medial malleolar fixation, placement of multiple transfibular or transtibial syndesmotic position screws, adjuvant external fixation, and application of locking plate technology [163].

Elderly Patients: Ankle fractures in elderly patients can be classified according to a young patient's cohort [78]. The Lauge-Hansen classification can be used for closed fracture reduction using reversed injury mechanisms to avoid unsuccessful or poor fracture reduction with soft tissue damage in geriatric patients [78]. Geriatric patients may have difficulty adhering to weight-bearing restrictions [178]. Alternative or augmented fixation methods may be considered to protect geriatric patients who cannot comply fully with weight-bearing restrictions [178]. Augmentation of a construct used to treat AO/Orthopaedic Trauma Association type 44-B fractures with an intramedullary wire and cement allowed immediate weight bearing with no cases of nonunion in a 2011 study [178]. Tibiotalocalcaneal nailing and early weight bearing have been used with good results in geriatric patients [178]. In a 2014 study, tibiotalocalcaneal nailing returned 90% of patients to their preinjury functional level [178]. Other authors have suggested multiple transfibular-transtibial screw fixation depending on the patient’s bone quality [178].

Pediatric Patients: Therapeutic objectives for ankle fractures in children should be to achieve an adequate functional axis of the ankle without articular gaps, and to protect the physis in order to avoid growth alterations [79]. The authors use a treatment algorithm starting with conservative management for nondisplaced pediatric supination-inversion ankle injuries, followed by successful surgical management for displaced fractures [120].

General Outcomes and Counseling: Five years after surgical fixation of an unstable ankle fracture, patients will still have some functional and physical residual effect [24]. Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities [154].

Complications and Outcomes

Most patients have good outcomes following ankle fracture, but there are a range of potential complications [46]. Wound infection/dehiscence rates are 1%–10% following ankle fractures [46]. Superficial infections can often be treated

Complications

General Outcomes: Most patients achieve good outcomes following ankle fracture, though the condition carries a high incidence of complications with residual pain affecting more than one-third of all patients [130]. The impact of life extends beyond short-term discomfort into many areas of daily living [60]. Common adverse outcomes include wound infection or dehiscence, loss of reduction, thromboembolism, symptomatic hardware, osteoarthritis, nonunion, compartment syndrome, and neuroma [46]. Postoperative complications correlate with the development of osteoarthritis and result in significantly worse patient-reported outcomes [46].

Wound and Infection Complications: Wound infection or dehiscence occurs at a rate of 1%–10% following ankle fractures [46]. Superficial infections are often managed with antibiotics and dressings, while deep infections may respond to suppression antibiotics until fracture union but usually require surgical debridement and bacteriologic specimens [46]. Exposed hardware may necessitate removal and the use of a spanning external fixator until infection eradication [46]. Wound complications are more common in trimalleolar fractures than in bimalleolar fractures [145]. In diabetic patients, rates of wound infection reach up to 32% [46]. Surgical site complications account for almost half of reported readmissions after ORIF [124]. Preoperative decubitus heel ulceration is associated with elevated risks of both short-term complications and long-term surgical failure following ORIF [138].

Thromboembolism: Deep vein thrombosis (DVT) occurs at a rate of 3% and pulmonary embolism (PE) at a rate of 0.3% following ankle fractures [46]. Chemoprophylaxis for thromboembolism is of uncertain efficacy [46]. In a subset of 566 patients undergoing hindfoot and ankle surgery, anticoagulant prophylaxis decreased the incidence of venous thromboembolism from 1.4% to 0.4% [181]. In the same subset, anticoagulant prophylaxis increased adverse bleeding events from 0.7% to 1.4% [181]. Patients receiving anticoagulant prophylaxis had a significantly lower risk of venous thromboembolism compared with those who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio of 0.38 (95% confidence interval, 0.25 to 0.56; P < 0.001) [181]. Conversely, patients receiving prophylaxis had a significantly higher risk of bleeding adverse events than those who did not (115 [2.2%] versus 55 [1.0%]; odds ratio, 2.18; 95% confidence interval, 1.55 to 3.09; P < 0.001) [181].

Hardware and Fixation Complications: Symptomatic hardware varies depending on the type and location of the fixation device [46]. Removal of symptomatic hardware is effective in 50% of patients, and removal of metalwork results in an improvement in patient-reported outcomes in only 50% of patients [46]. High rates of fixation failure have been reported in elderly patients [46]. Loss of reduction occurs at a rate of 0%–2% following ankle fractures [46]. This complication is most common in conservatively treated, unstable fractures [46]. In surgically treated fractures, loss of reduction may be related to inadequate initial reduction, inadequate fixation, poor bone stock, peripheral neuropathy, or psychiatric illness [46]. Malunion increases the risk of osteoarthritis [46].

Osteoarthritis: Osteoarthritis is rare in low-energy fractures but occurs in up to 30% of unstable patterns [46]. It may take several decades to become evident, with the mean time from ankle fracture to end-stage osteoarthritis being 21 years [46]. Osteoarthritis is more prevalent when anatomical reduction of the mortise is not achieved and may be related to chondral injury at the time of injury [46]. Trauma is the most common cause of ankle osteoarthritis, with 39% of cases in a recent series secondary to ankle fracture [46]. Risk factors include AO/OTA type C fracture patterns, high BMI, dislocation, and increased age [46]. Cartilage damage predicted posttraumatic osteoarthritis at a mean follow-up of almost 13 years [46]. No correlation was found between the number of cartilage lesions and outcome, but worse outcomes were associated with deeper lesions and those located on the anterior or lateral talus or the medial malleolus [46]. The most common site of articular cartilage damage is the talus, followed by the distal tibia and fibula, and finally the medial malleolus [46].

Nonunion: Nonunion is most commonly encountered after nonoperative treatment of ankle fractures [46]. It is often asymptomatic, but if painful, it may require revision fixation and possibly bone grafting [46].

Other Considerations: Compartment syndrome is rare and associated with high-energy fractures [46]. The superficial peroneal, sural, and saphenous nerves are at risk in the subcutaneous layer, and injury may result in a patch of anesthetic or dysesthetic skin [46]. Complex regional pain syndrome (CRPS) and pulmonary embolism are less common complications of ankle fractures [46]. Diabetic patients present a unique clinical challenge due to increased risk of complications regardless of treatment modality [4]. Higher complication rates are seen in unstable ankle fractures in diabetic patients regardless of surgical or nonsurgical treatment [4]. Open ankle fractures in patients with diabetes are limb-threatening injuries with high amputation and infection rates despite contemporary techniques of open reduction and internal fixation, intravenous antibiotics, and emergent irrigation and debridement [168]. In a study of 14 open ankle fractures in 13 patients with diabetes, 9 of 14 extremities (64%) had wound healing complications [168]. In the same study, five patients (six extremities; 42%) had below-knee amputation [168]. Only three of 14 fractures in three patients healed without complications in the study of open ankle fractures in diabetic patients [168]. The most frequent grade of injury for open ankle fractures was Gustilo Anderson grade IIIa, which accounted for 40% of cases [7]. The mean age of patients with Gustilo Anderson grade IIIa open ankle fractures was 61 years, which was higher than other grades of injury (p = 0.005) [7]. The mean Injury Severity Score (ISS) increased as the Gustilo Anderson grade increased (PC r = 0.15, p = 0.02), when one patient with a Gustilo Anderson grade IIIc fracture was excluded [7]. 11.5% of patients visited the emergency department within 90 days after ankle fracture ORIF, with the greatest incidence occurring within the first 2 weeks [31]. Short-term complications following ankle fracture surgeries such as 30-day ED visits, readmissions, and reoperations represent a significant burden to the healthcare system [59]. Despite a low adverse event rate, 2% of patients required unplanned readmission after ORIF for ankle fractures [124]. Complications were identified at similar rates when postoperative radiographs were taken during early postoperative visits and later ones [181]. Obese patients have significantly worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture [67]. Most patients experience notable pain immediately after ankle fracture fixation despite commonly used opioid regimens [68]. Surgically treated ankle fractures in the elderly treated in a certified geriatric fracture center seem to have limited negative effect on their quality of life [153]. The findings of a study allow for the identification of patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture [85].

Recovery

Rehabilitation protocol: In patients who underwent surgical fixation of unstable ankle fractures, early weight-bearing and range-of-motion exercise improved early function but did not improve time to return to work compared with late protocols [40].

Functional milestones: For 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 [125]. In National Football League athletes with distal fibula fractures, time to return to play depended on both the fracture pattern and whether surgery was required, ranging from 72 to 145 days [197].

Other Considerations: There is no consensus on a core set of primary outcome measures used in interventional trials for ankle fractures [3]. Short-term complications following ankle fracture surgeries, including 30-day emergency department visits, readmissions, and reoperations, represent a significant burden to the healthcare system [59]. Specifically, 11.5% of patients visited the emergency department within 90 days after ankle fracture open reduction and internal fixation, with the greatest incidence occurring within the first 2 weeks [31]. The incidence and time course of acute venous thromboembolism after lower extremity orthopaedic surgeries varies significantly depending on the surgical procedure, with Achilles tendon repair and ankle fracture surgery showing higher risks and protracted time courses [198]. Chondral and/or osteochondral lesions appear very frequently after ankle fractures [15], and were frequently found in association with acute ankle fractures at medium-term follow-up, where the severity of the fracture was associated with an increased number of osteochondral lesions [196].

Risk stratification is critical for predicting outcomes. The mFI-5, a composite index of comorbidity burden and functional status, effectively stratifies patients by risk and is associated with markedly elevated short- and long-term morbidity, mortality, and healthcare utilization following surgical treatment of ankle fractures [143]. Long-term risk stratification is important in patients with peripheral artery disease undergoing ankle fracture fixation [5]. In geriatric populations, other patient characteristics may play a more prominent role in determining one year mortality following ankle fractures than age alone [27]. Age does not dictate the treatment of ankle fractures in the elderly; rather, it is the type of fracture and the extent of displacement that should determine the course of treatment [199].

Key Evidence

• [L5] It is essential that future studies continue to investigate mechanism of injury, fracture patterns, and optimal treatments for ankle fractures. [1] (10.1007/s11999-015-4306-x)
• [L5] Current controversy remains in the management of ankle fractures. [2] (10.1097/bot.0000000000001503)
• [L2] The review identified a wide variety of outcome measures used in interventional trials for ankle fractures, with no consensus on a core set of primary outcomes. [3] (10.1186/s12891-019-2770-2)
• [L3] These findings underscore the importance of long-term risk stratification in patients with PAD undergoing ankle fracture fixation. [5] (10.5435/jaaos-d-25-01630)
• [L4] Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery due to resource limitations, knowledge deficits, and lack of treatment standardization. [6] (10.2106/jbjs.20.00660)
• [Paper] [7] (10.1007/s00402-014-2140-3)
• [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. [8] (10.1007/s00402-015-2376-6)
• [L4] Recognition of the ankle fracture component is important as it may alter the surgical plan and postoperative management. [9] (10.1007/s00402-014-2095-4)
• [L3] The findings do not support obtaining routine radiographs at the early outpatient visit in an ankle fracture patient without clinical signs of a complication. [10] (10.1016/j.injury.2016.09.008)
• [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. [11] (10.1007/s00167-020-06187-y)
• [L4] Stable ankle fracture patients form a distinct, clinically benign group in which functional treatment can be used. [12] (10.1016/s0020-1383(03)00207-9)
• [L4] One year after surgically treated ankle fractures a majority of patients continue to have symptoms and reported functional limitations. [13] (10.1186/1471-2474-8-127)
• [L3] More than two thirds of the fractures were caused by a low-energy trauma and ankle fractures are more frequent among females. [14] (10.1186/s12891-018-2326-x)
• [L1] CL and/or OCL appear very frequently after ankle fractures. [15] (10.1007/s00402-020-03647-5)
• [L3] Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. [16] (10.1186/s12891-021-04144-5)
• [L3] Surgical management of ankle fractures is the treatment of choice despite the fragility of the elderly population. [17] (10.1016/j.otsr.2016.03.004)
• [L4] [18] (10.1186/s12891-026-09755-4)
• [Paper] Early postoperative weight bearing initiated within approximately 2 weeks after open reduction and internal fixation of ankle fractures appears safe in selected patients with anatomically reduced fractures and rigid internal fixation and has not been shown to increase complication or hardware failure rates compared with delayed weight bearing in available studies. [20] (10.2106/jbjs.rvw.26.00038)
• [L3] The radiological result is not associated with a good functional outcome. [22] (10.1186/s13018-024-04820-x)
• [L5] A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries. [23] (10.5435/00124635-200107000-00007)
• [L3] Five years after surgical fixation of an unstable ankle fracture, patients will still have some functional and physical residual effect. [24] (10.1016/j.injury.2007.06.002)
• [Paper] This suggests that other patient characteristics may play a more prominent role in determining one year mortality following geriatric ankle fractures. [27] (10.1016/j.injury.2015.05.020)
• [L4] Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. [29] (10.1016/j.arthro.2016.08.016)
• [L5] The goals of treatment for ankle fractures are a healed fracture and an ankle that moves and functions normally without pain. [30] (10.2106/00004623-199611000-00021)
• [L3] 11.5% of patients visited the ED within 90 days after ankle fracture ORIF, with the greatest incidence occurring within the first 2 weeks. [31] (10.5435/jaaos-d-22-00484)
• [L5] It can be performed for the evaluation and management of syndesmotic injury, and for persistent pain following the definitive treatment of ankle fractures. [32] (10.1177/2325967119s00450)
• [L3] [33] (10.1016/j.injury.2005.01.004)
• [L2] The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. [34] (10.1186/s12891-021-04560-7)
• [L3] An analysis of the imaging features of such fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options. [37] (10.1186/s12891-018-1982-1)
• [L4] Based on this study, radiograph measurement of the degree of ankle swelling at the time of initial ED presentation seems to be statistically significant for prediction of an occult ankle fracture. [38] (10.5435/jaaosglobal-d-23-00271)
• [L4] There is a lack of high quality literature concerning the treatment of patients with open ankle fractures. [39] (10.1007/s00402-011-1349-7)
• [L1] [40] (10.2106/jbjs.16.01382)
• [L1] Early weight-bearing following ankle fracture surgery results in superior functional outcomes and equivalent safety compared to delayed protocols. [41] (10.1186/s13018-025-06216-x)
• [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. [42] (10.1016/j.otsr.2021.103137)
• [L1] Both surgical and conservative care of displaced or unstable ankle fractures in adults result in similar functional outcomes and are both appropriate treatment methods. [44] (10.1177/2325967121s00892)
• [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. [45] (10.1186/s12891-022-05358-x)
• [L3] Immediate surgical fixation of closed ankle fractures in patients with preoperatively neglected type 2 diabetes showed similar ankle scores to non-diabetic controls and did not worsen the final prognosis, suggesting immediate intervention is appropriate. [50] (10.1016/j.injury.2009.01.124)
• [L2] We recommend that, unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture. [53] (10.2106/jbjs.h.01852)
• [L3] PAD is an underdiagnosed condition in geriatric patients presenting with ankle fractures. [54] (10.1007/s00264-017-3705-x)
• [Paper] The procedure is indicated in all ankle fractures undergoing open reduction and internal fixation with no absolute contraindications. [55] (10.1016/j.eats.2019.01.014)
• [L1] Non-operative treatment of well-reduced ankle fractures in the elderly results in significantly better functional outcomes and lower costs compared to operative treatment. [58] (10.1007/s004020000172)
• [L3] Short-term complications following ankle fracture surgeries such as 30-day ED visits, readmissions, and reoperations represent a significant burden to the healthcare system. [59] (10.1016/j.injury.2020.07.044)
• [L4] The nature of life impact following ankle fractures can extend beyond short term pain and discomfort into many areas of life. [60] (10.1186/1471-2474-13-224)
• [L1] [61] (10.1016/j.injury.2013.02.018)
• [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. [62] (10.1016/j.arthro.2015.03.043)
• [Paper] The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. [63] (10.1016/j.injury.2016.07.025)
• [L4] Patients referred from other units underwent more procedures, but similar functional outcomes were achieved, highlighting the importance of managing open ankle fractures in an ortho-plastic specialist centre. [64] (10.1016/j.injury.2014.12.017)
• [L3] Obese patients have significant worse long-term outcomes, namely increased pain, poorer function, and greater impairment in everyday life after an operatively treated ankle fracture. [67] (10.1186/s12891-022-05247-3)
• [L2] Most patients experience notable pain immediately after ankle fracture fixation despite commonly used opioid regimens, indicating that current methods may not be sufficient. [68] (10.5435/jaaosglobal-d-18-00021)
• [L5] The key issue in achieving good outcomes when treating ankle fractures is restoring the stability and alignment of the fractured ankle using either non-operative or operative treatment as appropriate. [70] (10.1302/2058-5241.3.170057)
• [L4] It is suggested that in ankle fractures with suspicion of syndesmosis disruption, ankle arthroscopy may be helpful in clarifying the diagnosis and facilitating treatment. [71] (10.1016/j.injury.2004.10.002)
• [L1] This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. [72] (10.1186/s13018-024-05032-z)
• [L4] The procedure provides efficient and reliable stabilization for unstable ankle fractures in exceptional situations but should be limited to emergencies or cases where conventional methods are inadvisable. [73] (10.2106/00004623-196547070-00004)
• [L5] Management of ankle fractures depends on stability; stable fractures are managed nonsurgically while unstable fractures require open reduction and internal fixation. [74] (10.5435/00124635-200311000-00004)
• [L4] Multiple factors must be considered in deciding whether to address the posterior malleolus fracture surgically, although current indications are unclear. [76] (10.5435/00124635-201402000-00001)
• [L5] [78] (10.1530/eor-22-0082)
• [L5] Therapeutic objectives should be to achieve an adequate functional axis of the ankle without articular gaps, and to protect the physis in order to avoid growth alterations. [79] (10.1302/2058-5241.6.200042)
• [L4] Open reduction and internal fixation of ankle fractures in older patients is an effective option for the majority of patients. [80] (10.1016/s0020-1383(12)70011-6)
• [L2] Recovery of normal ankle dorsiflexion flexibility typically takes longer than the initial period of immobilization. [81] (10.1097/blo.0b013e31802fc161)
• [L2] [84] (10.1186/s12891-016-1063-2)
• [L3] The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture. [85] (10.2106/jbjs.23.00745)
• [L5] A Delphi consensus was reached on specific imaging techniques, anatomical aspects, and fracture reduction parameters for evaluating wrist and ankle fractures. [86] (10.1007/s00402-010-1198-9)
• [L2] On the basis of our study we do not recommend MR imaging as an important factor in choosing between operative and nonoperative treatment of an SER-type ankle fracture. [87] (10.2106/jbjs.m.01533)
• [L2] Traditional radiographic measurements should not be relied on solely for determining if the syndesmosis is intact and the ankle mortise is stable. [88] (10.1097/01.blo.0000161090.86162.19)
• [L1] After surgery for ankle fracture, early weight-bearing was noninferior to delayed weight-bearing and is likely cost-effective. [89] (10.2106/jbjs.24.01398)
• [L3] Ethnicity and fracture pattern are factors associated with pain at the time of presentation of an acute ankle fracture, with unstable patterns and medial bony injuries contributing significantly to pain. [91] (10.1016/j.injury.2015.05.009)
• [L5] Treatment of ankle fractures in the elderly remains challenging due to comorbidities, soft tissue trauma, and compliance issues, requiring adapted diagnostic and therapeutic strategies. [93] (10.1530/eor-23-0052)
• [L5] Non-operative management of ankle fractures in diabetic patients results in higher complication rates compared to operative management. [94] (10.1302/2058-5241.5.200025)
• [Paper] [95] (10.1016/j.csm.2008.01.002)
• [L5] All three variables (shortening, lateral shift, and external rotation), alone and in combination, increased contact pressures in the ankle joint. [100] (10.2106/00004623-199712000-00006)
• [Paper] These results suggest that metabolic syndrome should be treated together with ankle fractures. [105] (10.1016/j.injury.2019.05.033)
• [L4] The DAFC system offers a reliable and comprehensive framework for ankle fracture classification, with the added benefit of prognostic insights, particularly regarding dislocation and posterior malleolus involvement. [109] (10.1186/s13018-025-05539-z)
• [L4] The Weber classification was found to be a predictor of outcome in unimalleolar ankle fractures and not for multimalleolar fractures. [110] (10.1016/s0020-1383(98)00116-8)
• [L4] Conventional radiography and MRI are not sufficient in assessing syndesmotic disruption, and MRA can make an important contribution to diagnosis in ankle fractures. [111] (10.1007/s00402-004-0721-2)
• [Paper] Consequently, we conclude that classifications of ankle fractures in the SFR are accurate and valid. [112] (10.1016/j.injury.2016.05.028)
• [L4] Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. [115] (10.1016/j.otsr.2018.03.008)
• [L3] Non-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome. [116] (10.1016/j.injury.2019.03.010)
• [L1] ARIF and ORIF are comparable in terms of providing pain relief and improving function for patients with ankle fractures. [117] (10.1186/s13018-023-03597-9)
• [L1] After a year no significant differences were found, and treatment with a brace is a safe and more comfortable option for stable type B ankle fractures. [118] (10.1016/j.injury.2018.06.009)
• [L5] The authors use a treatment algorithm starting with conservative management for nondisplaced fractures, followed by successful surgical management for displaced fractures. [120] (10.5435/jaaosglobal-d-23-00284)
• [L3] [123] (10.1016/j.injury.2017.04.053)
• [L3] Despite a low adverse event rate, 2% of patients required unplanned readmission after ORIF for ankle fractures, with surgical site complications accounting for almost half of reported readmissions. [124] (10.1186/s13018-024-04895-6)
• [L1] In adults aged <65 years with unstable ankle fractures, fibular nailing did not differ from ORIF for functional outcome at 1 year. [125] (10.2106/jbjs.22.00486)
• [L4] [126] (10.1186/s12891-024-07884-2)
• [L3] The study concluded that outpatient management of isolated ankle fractures is safe and offers substantial economic benefits. [127] (10.1053/j.jfas.2019.09.030)
• [Paper] [128] (10.1016/s0020-1383(02)00077-3)
• [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. [129] (10.1016/j.injury.2007.09.011)
• [L3] Ankle fracture has a high incidence and complication rate, with residual pain affecting more than one-third of all patients, presenting a significant societal impact in terms of patient outcomes and payer burden. [130] (10.1186/s12891-022-06095-x)
• [L5] [131] (10.5435/00124635-200803000-00007)
• [L5] [133] (10.2106/jbjs.17.01658)
• [L4] [134] (10.1302/0301-620x.99b7.bjj-2016-1087.r1)
• [L2] Results from this trial will contribute to an evidence-based approach for rehabilitation after ankle fracture. [135] (10.1186/1471-2474-7-46)
• [L3] Preoperative decubitus heel ulceration is associated with elevated risks of both short-term complications and long-term surgical failure following ORIF for ankle fractures. [138] (10.5435/jaaos-d-25-01184)
• [L3] Where medically or socially appropriate, ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society. [139] (10.5435/jaaos-d-16-00897)
• [L1] Early weightbearing after the operative treatment of an unstable ankle fracture was not inferior to nonweightbearing in terms of OMAS assessed at 12 months after injury. [140] (10.1177/03635465211026960)
• [L1] The authors do not recommend using a tourniquet for osteosynthesis of ankle fractures. [141] (10.1097/01.blo.0000151849.37260.0a)
• [L5] Stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. [142] (10.2106/00004623-199607000-00006)
• [L3] The mFI-5, a composite index of comorbidity burden and functional status, effectively stratifies patients by risk and is associated with markedly elevated short- and long-term morbidity, mortality, and healthcare utilization following surgical treatment of ankle fractures. [143] (10.5435/jaaos-d-25-00807)
• [L3] Wound complications were more common in those with trimalleolar ankle fractures than in those with bimalleolar fractures. [145] (10.1053/j.jfas.2012.10.013)
• [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. [150] (10.2106/jbjs.23.01088)
• [L3] Surgically treated ankle fractures in the elderly treated in a certified geriatric fracture center seem to have limited negative effect on their quality of life. [153] (10.1016/j.injury.2018.06.030)
• [L3] Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. [154] (10.1016/j.injury.2019.09.014)
• [L5] Surgical reduction of a small posterior malleolar fragment with less than 25% ankle joint surface improves pressure distribution but does not affect ankle joint stability. [155] (10.1302/0301-620x.100b1.bjj-2017-0435.r1)
• [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. [157] (10.1177/2325967118s00159)
• [L5] Movements were consistently greater in the sagittal plane than the coronal plane, and distal tibio-fibular instability should be assessed in the sagittal plane. [159] (10.1016/j.injury.2003.10.013)
• [L5] In the absence of severe systemic comorbidities, the results after open reduction and internal fixation of malleolar fractures in patients above and below 60 years of age are nearly identical, while nonoperative treatment of unstable fractures leads to significantly inferior outcomes. [166] (10.1302/2058-5241.1.000023)
• [L4] [168] (10.1097/01.blo.0000084402.53464.90)
• [L4] The proposed classification system based on CT examination may be a useful indication for surgery and defining the most useful approach to these injuries. [170] (10.1007/s00402-015-2171-4)
• [L1] Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. [180] (10.2106/jbjs.19.01381)
• [L3] MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. [182] (10.1007/s00167-019-05581-5)
• [L2] A protocol including computed tomography of the ankle may detect more injuries in a larger study. [183] (10.1007/s11999-008-0224-5)
• [L4] MRI is a necessary component of the work-up of every painful ankle to avoid long-term sequalae, misdiagnosis, and managed patient expectations to allow for return of activities of daily living and sports. [184] (10.1177/2325967125s00001)
• [L4] MRI can show severe bone injuries that are not visible radiographically in ice hockey players. [185] (10.1177/0363546515626181)
• [L3] [186] (10.1186/s13018-023-03558-2)
• [L4] Patients with noncomminuted lateral malleolar fractures could be diagnosed with a stable ankle mortise without further stress testing when the fracture line widths were <2 mm on lateral radiographs. [187] (10.2106/jbjs.16.00450)
• [L4] Trimalleolar ankle fractures are considered unstable and generally treated operatively, with computed tomography playing a key role in planning. [189] (10.1302/2058-5241.6.200138)
• [L4] Performing CT assessment in all patients suspected to have or diagnosed with posterior malleolar fractures on standard radiographs will increase the number of reported cases of PVPM fractures and enable more accurate surgical planning, thereby resulting in better clinical and radiological outcomes. [190] (10.1016/j.otsr.2017.05.012)
• [L4] In our study, use of arthroscopy before open ankle fracture fixation identified intra-articular pathology in 84.2% of subjects. [191] (10.1016/j.asmr.2020.08.020)
• [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. [195] (10.1016/s0020-1383(99)00187-4)
• [L3] OCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. [196] (10.1016/j.injury.2015.10.029)
• [L4] Time to return to play depended on both the fracture pattern and whether surgery was required and ranged from 72 to 145 days. [197] (10.1177/2325967117726515)
• [L3] The incidence and time course of acute VTE after lower extremity orthopaedic surgeries varies significantly depending on the surgical procedure, with Achilles tendon repair and ankle fracture surgery showing higher risks and protracted time courses. [198] (10.5435/jaaos-d-23-00495)
• [L4] This study has demonstrated that age does not dictate the treatment of ankle fractures in the elderly, but it is the type of fracture and the extent of displacement that should determine the course of treatment. [199] (10.1016/0020-1383(93)90202-h)

See Also

• Ankle fracture fixation
• Syndesmotic injury
• Ankle arthroscopy
• Ankle osteoarthritis
• Achilles tendon repair

References

[1] Classifications in Brief: Lauge-Hansen Classification of Ankle Fractures. Clinical Orthopaedics and Related Research®. 2015. DOI: 10.1007/s11999-015-4306-x

[2] Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations. Journal of Orthopaedic Trauma. 2019. DOI: 10.1097/bot.0000000000001503

[3] Primary outcome measures used in interventional trials for ankle fractures: a systematic review. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2770-2

[4] Aaos Comprehensive Orthopaedic Review 3. The Diabetic Foot and Ankle > V. Diabetic Ankle Fractures.

[5] The Influence of Peripheral Artery Disease on Postoperative Complications Following Open Reduction and Internal Fixation for Ankle Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-25-01630

[6] Improving Management of Adult Ankle Fractures in Malawi. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00660

[7] Open ankle fractures: who gets them and why?. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-014-2140-3

[8] 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

[9] Ankle injuries in distal tibial spiral shaft fractures: results from an institutional change in imaging protocol. Archives of Orthopaedic and Trauma Surgery. 2014. DOI: 10.1007/s00402-014-2095-4

[10] The role of outpatient visit after operative treatment of ankle fractures. Injury. 2016. DOI: 10.1016/j.injury.2016.09.008

[11] High incidence of (osteo)chondral lesions in ankle fractures. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06187-y

[12] Improvement in the treatment of stable ankle fractures: an audit based approach. Injury. 2004. DOI: 10.1016/s0020-1383(03)00207-9

[13] Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Musculoskeletal Disorders. 2007. DOI: 10.1186/1471-2474-8-127

[14] Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 2009–2013 and classified according to AO/OTA. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2326-x

[15] Incidence of concomitant chondral/osteochondral lesions in acute ankle fractures and their effect on clinical outcome: a systematic review and meta-analysis. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03647-5

[16] Operatively treated ankle fractures in Switzerland, 2002–2012: epidemiology and associations between baseline characteristics and fracture types. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04144-5

[17] Analysis of risk factors of the postoperative complications of surgical treatment of ankle fractures in the elderly: A series of 477 patients. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2016.03.004

[18] Epidemiology of non-unions following foot and ankle fractures: a nationwide analysis from 2014 to 2023. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09755-4

[19] Rockwood And Green S Fractures In Adults. 9: Principles of Nonoperative Management of Fractures > Ankle Fractures.

[20] Postoperative Weight-Bearing Protocols Following Open Reduction and Internal Fixation of Ankle Fractures: Current Evidence, Controversies, and Future Directions. JBJS Reviews. 2026. DOI: 10.2106/jbjs.rvw.26.00038

[22] Clinical, functional and radiological outcome after osteosynthesis of ankle fractures using a specific provocation test. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04820-x

[23] Pediatric Ankle Fractures: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200107000-00007

[24] Five-year functional outcome analysis of ankle fracture fixation. Injury. 2007. DOI: 10.1016/j.injury.2007.06.002

[27] Evaluation of one-year mortality after geriatric ankle fractures in patients admitted to nursing homes. Injury. 2015. DOI: 10.1016/j.injury.2015.05.020

[29] Role of Ankle Arthroscopy in Management of Acute Ankle Fracture. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.08.016

[30] Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Fractures of the Ankle and the Distal Part of the Tibia†. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199611000-00021

[31] Ninety-Day Emergency Department Visits After Ankle Fracture Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00484

[32] Role of Arthroscopy in Ankle Fracture Surgery. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00450

[33] Five years of ankle fractures grouped by stability. Injury. 2005. DOI: 10.1016/j.injury.2005.01.004

[34] Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04560-7

[35] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Clinical Assessment of Ankle Fractures.

[37] Pre-operative radiographic findings predicting concomitant posterior malleolar fractures in tibial shaft fractures: a comparative retrospective study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1982-1

[38] Probability of Occult Ankle Fracture Based on Radiograph-Measured Swelling. JAAOS: Global Research and Reviews. 2024. DOI: 10.5435/jaaosglobal-d-23-00271

[39] Evidence-based treatment of open ankle fractures. Archives of Orthopaedic and Trauma Surgery. 2011. DOI: 10.1007/s00402-011-1349-7

[40] Early, Rather than Late, Weight-Bearing and Range-of-Motion Exercise Improved Early Function But Not Time to Return to Work After Surgical Fixation of Unstable Ankle Fractures. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.01382

[41] Early weight-bearing after ankle fracture surgery: a systematic review and meta-analysis of functional outcomes and safety. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06216-x

[42] Treatment of bimalleolar fractures in elderly. Orthopaedics & Traumatology: Surgery & Research. 2022. DOI: 10.1016/j.otsr.2021.103137

[43] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Initial Assessment and Classification.

[44] Comparation of Clinical Outcome of Surgical vs. Conservative Management for Ankle Fracture Weber Type B: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967121s00892

[45] Fractures of the lateral malleolus – a retrospective before-and-after study of treatment and resource utilization following the implementation of a structured treatment algorithm. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05358-x

[46] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Management of Adverse Outcomes and Unexpected Complications in Ankle Fractures.

[47] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Abstract.

[49] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Posterior Malleolar Fractures.

[50] Results after immediate operations of closed ankle fractures in patients with preoperatively neglected type 2 diabetes. Injury. 2009. DOI: 10.1016/j.injury.2009.01.124

[51] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Management.

[53] Spinal Anesthesia Mediates Improved Early Function and Pain Relief Following Surgical Repair of Ankle Fractures. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01852

[54] Standardised pre-operative diagnostics and treatment of peripheral arterial disease reduce wound complications in geriatric ankle fractures. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3705-x

[55] Arthroscopically Assisted Reduction of Sagittal‐Plane Disruption of Distal Tibiofibular Syndesmosis. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2019.01.014

[56] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Imaging and Other Diagnostic Studies for Ankle Fractures > Radiography.

[58] The epidemic of ankle fractures in the elderly - is surgical treatment warranted?. Archives of Orthopaedic and Trauma Surgery. 2000. DOI: 10.1007/s004020000172

[59] Factors affecting emergency department visits, readmissions, and reoperations within 30 days of ankle fracture surgery- an institutional retrospective study. Injury. 2020. DOI: 10.1016/j.injury.2020.07.044

[60] Life impact of ankle fractures: Qualitative analysis of patient and clinician experiences. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-224

[61] Health status, health-related quality of life, and quality of life following ankle fractures: A systematic review. Injury. 2013. DOI: 10.1016/j.injury.2013.02.018

[62] Arthroscopy‐Assisted Surgery for Acute Ankle Fractures: A Systematic Review. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.03.043

[63] Relevance of adjacent joint imaging in the evaluation of ankle fractures. Injury. 2016. DOI: 10.1016/j.injury.2016.07.025

[64] Outcome of the management of open ankle fractures in an ortho-plastic specialist centre. Injury. 2015. DOI: 10.1016/j.injury.2014.12.017

[65] Aaos Comprehensive Orthopaedic Review 3. Pediatric Pelvic and Lower Extremity Fractures > VIII. Ankle Fractures.

[66] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC EXAMINATION AND DEBRIDEMENT OF THE ANKLE JOINT > ANKLE FRACTURES.

[67] The effect of BMI on long-term outcomes after operatively treated ankle fractures: a study with up to 16 years of follow-up. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05247-3

[68] Postoperative Pain After Surgical Treatment of Ankle Fractures: A Prospective Study. JAAOS: Global Research and Reviews. 2018. DOI: 10.5435/jaaosglobal-d-18-00021

[70] Stability in ankle fractures. EFORT Open Reviews. 2018. DOI: 10.1302/2058-5241.3.170057

[71] Arthroscopic assessment of the syndesmosis following ankle fracture. Injury. 2005. DOI: 10.1016/j.injury.2004.10.002

[72] The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05032-z

[73] Vertical Transarticular-Pin Fixation for Unstable Ankle Fractures. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547070-00004

[74] Ankle Fractures Resulting From Rotational Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200311000-00004

[75] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Syndesmosis Injury.

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

[77] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Imaging.

[78] Ankle fractures of the geriatric patient: a narrative review. EFORT Open Reviews. 2023. DOI: 10.1530/eor-22-0082

[79] Ankle fractures in children. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200042

[80] L-T1.6 Ankle fractures in older patients: the use of augmented fixation techniques. Injury. 2012. DOI: 10.1016/s0020-1383(12)70011-6

[81] Passive Dorsiflexion Flexibility after Cast Immobilization for Ankle Fracture. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e31802fc161

[82] Miller S Review Of Orthopaedics. ANKLE FRACTURES.

[84] The value of arthroscopy in the treatment of complex ankle fractures – a protocol of a randomised controlled trial. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1063-2

[85] Complications After Ankle Fracture Surgery in Finland Between 1998 and 2020. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00745

[86] How to evaluate the quality of fracture reduction and fixation of the wrist and ankle in clinical practice: a Delphi consensus. Archives of Orthopaedic and Trauma Surgery. 2010. DOI: 10.1007/s00402-010-1198-9

[87] Stability Assessment of the Ankle Mortise in Supination-External Rotation-Type Ankle Fractures: Lack of Additional Diagnostic Value of MRI. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01533

[88] Radiographic Measurements Do Not Predict Syndesmotic Injury in Ankle Fractures. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000161090.86162.19

[89] After Surgery for Ankle Fracture, Early Weight-Bearing Was Noninferior to Delayed Weight-Bearing and Is Likely Cost-Effective. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.01398

[91] Factors affecting pain in acute ankle fractures: A prospective evaluation. Injury. 2015. DOI: 10.1016/j.injury.2015.05.009

[93] Ankle fractures in the elderly: Do we have new concepts?. EFORT Open Reviews. 2023. DOI: 10.1530/eor-23-0052

[94] Ankle fractures in diabetic patients. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.200025

[95] Foot and Ankle Fractures in Dancers. Clinics in Sports Medicine. 2008. DOI: 10.1016/j.csm.2008.01.002

[100] The Effect of Fibular Malreduction on Contact Pressures in an Ankle Fracture Malunion Model. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199712000-00006

[105] Impact of metabolic syndrome on patient outcomes of supination-external rotation ankle fracture. Injury. 2019. DOI: 10.1016/j.injury.2019.05.033

[109] A novel alphanumeric classification system for ankle fractures: clinical applications and evaluation. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05539-z

[110] An evaluation of the Weber classification of ankle fractures. Injury. 1998. DOI: 10.1016/s0020-1383(98)00116-8

[111] Magnetic resonance arthrographic evaluation of syndesmotic diastasis in ankle fractures. Archives of Orthopaedic and Trauma Surgery. 2004. DOI: 10.1007/s00402-004-0721-2

[112] Substantial accuracy of fracture classification in the Swedish Fracture Register: Evaluation of AO/OTA-classification in 152 ankle fractures. Injury. 2016. DOI: 10.1016/j.injury.2016.05.028

[114] Rockwood And Green S Fractures In Adults. 59: Patellar Fractures and Dislocations and Extensor Mechanism Injuries > Introduction to Ankle Fractures.

[115] Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks’ prospective follow-up of 14 patients. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.03.008

[116] Selective fixation of the medial malleolus in unstable ankle fractures. Injury. 2019. DOI: 10.1016/j.injury.2019.03.010

[117] Arthroscopically assisted versus open reduction internal fixation for ankle fractures: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03597-9

[118] Functional bracing treatment for stable type B ankle fractures. Injury. 2018. DOI: 10.1016/j.injury.2018.06.009

[120] Management of Pediatric Supination-inversion Ankle Injuries Involving Distal Tibia and Intraepiphyseal Distal Fibula Fractures. JAAOS: Global Research and Reviews. 2024. DOI: 10.5435/jaaosglobal-d-23-00284

[123] Standardised virtual fracture clinic management of radiographically stable Weber B ankle fractures is safe, cost effective and reproducible. Injury. 2017. DOI: 10.1016/j.injury.2017.04.053

[124] Readmission within 30-days of open reduction and internal fixation for ankle fractures: NSQIP analysis of 29,905 patients. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04895-6

[125] 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

[126] External validation of an artificial intelligence multi-label deep learning model capable of ankle fracture classification. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07884-2

[127] Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications, Readmissions, and Costs. The Journal of Foot and Ankle Surgery. 2020. DOI: 10.1053/j.jfas.2019.09.030

[128] Abstracts from the British Trauma Society Meeting, 2000; John Innes Centre, Norwich, Norfolk, 21–22 September 2000. Injury. 2002. DOI: 10.1016/s0020-1383(02)00077-3

[129] Cadaver specimens investigation of three articulated external fixator types for the human ankle joint. Injury. 2008. DOI: 10.1016/j.injury.2007.09.011

[130] Incidence, costs and post-operative complications following ankle fracture – A US claims database analysis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06095-x

[131] Complications of Ankle Fracture in Patients With Diabetes. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200803000-00007

[133] Techniques and Considerations for the Operative Treatment of Ankle Fractures in the Elderly. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.17.01658

[134] When is a simple fracture of the lateral malleolus not so simple?. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b7.bjj-2016-1087.r1

[135] Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628]. BMC Musculoskeletal Disorders. 2006. DOI: 10.1186/1471-2474-7-46

[138] Impact of Preoperative Heel Ulceration on Surgical Outcomes Following Open Reduction and Internal Fixation of Rotational Ankle Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-25-01184

[139] Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-16-00897

[140] Early Weightbearing Versus Nonweightbearing After Operative Treatment of an Ankle Fracture: A Multicenter, Noninferiority, Randomized Controlled Trial. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211026960

[141] Tourniquets May Increase Postoperative Swelling and Pain after Internal Fixation of Ankle Fractures. Clinical Orthopaedics and Related Research. 2005. DOI: 10.1097/01.blo.0000151849.37260.0a

[142] Motion of the Ankle in a Simulated Supination-External Rotation Fracture Model. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199607000-00006

[143] Frailty as a Predictor of Outcomes in Surgically Treated Ankle Fractures: A Propensity-Matched Cohort Analysis Using the mFI-5. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00807

[145] Factors Affecting Healing of Ankle Fractures. The Journal of Foot and Ankle Surgery. 2013. DOI: 10.1053/j.jfas.2012.10.013

[150] Assessing the Need for Additional Syndesmotic Stabilization in Open Reduction of the Posterior Malleolus. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.23.01088

[153] Outcome after surgical treatment of fragility ankle fractures in a certified orthogeriatric trauma center. Injury. 2018. DOI: 10.1016/j.injury.2018.06.030

[154] Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle. Injury. 2019. DOI: 10.1016/j.injury.2019.09.014

[155] The role of a small posterior malleolar fragment in trimalleolar fractures. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b1.bjj-2017-0435.r1

[157] Talar Motion is Constrained by Tricortical Screw Fixation of the Syndesmosis: A Cadaveric Robotic Study. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118s00159

[159] Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction?. Injury. 2004. DOI: 10.1016/j.injury.2003.10.013

[163] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > ANKLE FRACTURES IN PATIENTS WITH DIABETES.

[165] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Ankle Anatomy.

[166] Management of ankle fractures in the elderly. EFORT Open Reviews. 2016. DOI: 10.1302/2058-5241.1.000023

[168] Open Ankle Fractures in Patients With Diabetes Mellitus. Clinical Orthopaedics and Related Research. 2003. DOI: 10.1097/01.blo.0000084402.53464.90

[170] Anatomy and classification of the posterior tibial fragment in ankle fractures. Archives of Orthopaedic and Trauma Surgery. 2015. DOI: 10.1007/s00402-015-2171-4

[171] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Summary.

[178] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Geriatric Fractures.

[180] Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01381

[181] Orthopaedic Knowledge Update Trauma. Ankle Fractures > Postoperative Rehabilitation.

[182] MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05581-5

[183] High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures. Clinical Orthopaedics & Related Research. 2008. DOI: 10.1007/s11999-008-0224-5

[184] The Ankle Sprain: Not So Benign in the Young and Middle-aged Athlete. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00001

[185] Subradiographic Foot and Ankle Fractures and Bone Contusions Detected by MRI in Elite Ice Hockey Players. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546515626181

[186] Epidemiology of more than 50,000 ankle fractures in the Swedish Fracture Register during a period of 10 years. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03558-2

[187] Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.00450

[189] Current management of trimalleolar ankle fractures. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200138

[190] Open reduction in pilon variant posterior malleolar fractures: Radiological and clinical evaluation. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2017.05.012

[191] Identifying Intra‐Articular Pathology With Arthroscopy Prior to Open Ankle Fracture Fixation. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.08.020

[195] Routine radiography following ankle fracture fixation: a case for limiting its use. Injury. 1999. DOI: 10.1016/s0020-1383(99)00187-4

[196] High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: Medium-term follow-up of 100 cases. Injury. 2016. DOI: 10.1016/j.injury.2015.10.029

[197] Distal Fibula Fractures in National Football League Athletes. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117726515

[198] Incidence and Time Course of Symptomatic Thromboembolic Outcomes After Lower Extremity Arthroscopic Surgery, Ankle Fracture Surgery, and Achilles Tendon Repair. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00495

[199] Ankle fractures in the elderly: MUA versus ORIF. Injury. 1993. DOI: 10.1016/0020-1383(93)90202-h