Bimalleolar or Trimalleolar Fracture


  1. R/O loss of overlying skin integrity
  2. Check pulses, mortise disruption


  1. Early reduction w/in-line traction, splint
  2. Consult ortho, admit for ORIF
Isolated Malleolar and Distal Fibular Shaft Fractures:
  Initial Treatment
Splint type & position Lower extremity splint with ankle in neutral position
Initial follow-up visit 3 to 5 days for definitive casting
Pt instructions Non–weight bearing until definitive casting
Icing and elevation to minimize swelling
  Follow-up Care
Cast or Splint type & position Short-leg walking cast or walking cast fracture boot with the ankle in neutral position
Length of immobilization Malleolar: 4 to 6 weeks
Distal fibular: 6 to 8 weeks
Immobilization continued up to 8 weeks if there is no evidence of radiographic healing
Healing time 6 to 8 weeks
Possibly several months for complete radiographic healing
Follow-up visit interval Malleolar: at 4 weeks to assess healing
Distal fibular: every 2 to 4 weeks
Every 2 weeks after immobilization to assess ankle rehabilitation
Repeat radiography interval Malleolar: at 4 weeks to check for radiographic healing
Distal fibular: at 7 to 10 days to check positioning
Every 2 weeks if no healing at 4 weeks
Pt instruction Ankle ROM exercises, calf stretching, and strengthening after immobilization Regaining full dorsiflexion and peroneal muscle strength emphasized
Indications for Ortho consult Unstable fractures
Bimalleolar and trimalleolar fractures
Posterior malleolar fractures with >25% articular involvement >2 mm displacement Symptomatic nonunion

Associated and Occult Injuries of the Ankle:
Injury Clinical Suspicion Confirmatory Test
Important to identify in the ED
  Maisonneuve fracture Examine proximal fibula and shaft, tenderness to palpation Fibula radiograph
  Peroneal tendon dislocation Palpable anterior tendon dislocation or subluxation Clinical examination
Usually identified in follow-up of ankle sprains
  Osteochondral injuries Diffuse ankle swelling, passive plantar flexion Ankle mortise view/CT
  Syndesmosis tear Significant ankle pain, positive squeeze test Widened mortise with weightbearing
  Anterior calcaneal process fracture Tenderness more inferoanterior than a typical ankle sprain Lateral ankle radiograph/CT
  Lateral talar process fracture Tenderness just distal to the tip of fibula Ankle mortise view/CT
  Os trigonum Tenderness anterior to Achilles tendon Lateral ankle radiograph

Bimaleolar Fx

Trimaleolar Fx