Ankle Fracture

For visible deformity or suspected fracture-dislocation, examine and document dorsalis pedis and posterior tibial perfusion, capillary refill, motor function, sensory status, open wounds, and focal skin tenting before splinting or reduction. A dislocated ankle with threatened skin, vascular compromise, or neurologic deficit requires urgent reduction; urgent open reduction is necessary when closed reduction fails or neurovascular deficit is present. PubMedPubMedAnkle Fracture - StatPearls - NCBI Bookshelf

After reduction, repeat the neurovascular examination and obtain post-reduction ankle radiographs. Temporize an unstable fracture-dislocation with immobilization; when soft-tissue swelling makes immediate internal fixation unsafe, staged external fixation followed by definitive ORIF after soft-tissue recovery is an accepted pathway. Pin placement should avoid anticipated definitive surgical incisions. PubMedPubMedAnkle Fracture - StatPearls - NCBI Bookshelf

Do not localize the examination to the malleoli. Palpate the proximal fibula and assess for syndesmotic pain or mechanism suggestive of external rotation injury. A proximal fibular fracture may be clinically occult in patients presenting chiefly with ankle pain. PubMedPubMedAnkle Radiographic Evaluation - StatPearls - NCBI Bookshelf

Obtain ankle radiographs when malleolar pain is accompanied by bony tenderness along the posterior edge or tip of either malleolus, or inability to bear weight for four steps both immediately after injury and at assessment. For midfoot pain, obtain foot radiographs when there is navicular tenderness, fifth-metatarsal-base tenderness, or inability to bear weight for four steps. The Ottawa Ankle Rules are highly sensitive and can reduce unnecessary radiography. PubMed+2PubMedAcute Ankle Sprain - StatPearls - NCBI BookshelfPubMedOttawa Ankle Rules and Subjective Surgeon Perception to Evaluate Radiograph Necessity Following Foot and Ankle Sprain - PMCPubMedIMPLEMENTATION OF OTTAWA ANKLE RULES IN UNIVERSITY HOSPITAL EMERGENCY ROOM: PILOT STUDY

Order anteroposterior, mortise, and lateral ankle views. The mortise view best evaluates the tibiotalar joint space and talar alignment; in adults, the clear spaces should be symmetric and no greater than 4 mm. Weight-bearing radiographs are preferred when tolerated because they can reveal subtle alignment abnormalities or joint-space widening not apparent on non-weight-bearing images. PubMed+1PubMedAcute Ankle Sprain - StatPearls - NCBI BookshelfPubMedAnkle Radiographic Evaluation - StatPearls - NCBI Bookshelf

If initial films show a posterior malleolar fracture or displaced medial malleolar fracture without a distal fibular fracture, scrutinize the syndesmosis and medial clear space. Associated widening implies possible force transmission to the proximal fibula; obtain anteroposterior and lateral radiographs of the tibia and fibula to identify a Maisonneuve injury. PubMedPubMedAnkle Radiographic Evaluation - StatPearls - NCBI Bookshelf

A stable, concentrically reduced ankle mortise can be managed nonoperatively with immobilization and progressive weight bearing as tolerated. Stable nonsurgical fractures commonly return toward baseline function in approximately 6 to 8 weeks. PubMedPubMedAnkle Fracture - StatPearls - NCBI Bookshelf

ORIF is generally indicated for an unstable ankle mortise in patients fit for surgery when soft-tissue conditions permit. Fracture-dislocation, talar shift, unstable bimalleolar or trimalleolar patterns, and demonstrated syndesmotic instability are operative patterns because restoration and maintenance of a congruent mortise is the therapeutic objective. PubMed+1PubMedAnkle Fracture - StatPearls - NCBI BookshelfclinicaltrialsStudy Details | NCT03362229 | Medial Malleolus: Operative Or Non-operative | ClinicalTrials.gov

Timing should balance reduction and skin protection against wound risk. Definitive fixation is often performed within 24 hours, but can be delayed for several days when swelling requires soft-tissue recovery; a staged approach is appropriate when immediate definitive fixation would compromise wound healing. PubMedPubMedAnkle Fracture - StatPearls - NCBI Bookshelf

Traditional care after ORIF of unstable ankle fractures with syndesmotic screw stabilization has often used 6 to 8 weeks of non-weight-bearing. A case series reported full weight bearing within 15 days after ORIF with trans-syndesmotic screws without loss of reduction, hardware failure, or increased complications, supporting early protected weight bearing in selected patients. ScienceDirectScienceDirectEarly Protected Weightbearing After Open Reduction Internal Fixation of Ankle Fractures With Trans-syndesmotic Screws - ScienceDirect

Randomized and observational evidence summarized in recent reports supports earlier mobilization after stable operative fixation. A multicenter randomized trial comparing immediate protected weight bearing with casted non-weight-bearing reported better 6-week Olerud-Molander scores (43 versus 35) and better early ankle range of motion in the immediate-weight-bearing group. orthobuzz jbjsorthobuzz jbjsFracture Care Is at the Heart of Orthopaedic Surgery - OrthoBuzz A 2025 retrospective cohort found no statistically significant difference in complications across early, intermediate, and delayed weight-bearing groups after ankle ORIF. ScienceDirect+1ScienceDirectEarly weight bearing is not associated with short-term complications in ankle fractures - ScienceDirectScienceDirectEarly Weight Bearing Is Not Associated with Short-Term Complications in ...

Prescribe loading only after the treating surgeon confirms acceptable reduction, construct stability, and wound status. Delay or restrict weight bearing when the fixation construct, postoperative radiographs, soft tissues, or patient-specific capacity to comply makes early loading unsafe; the literature and postoperative protocols remain variable. ScienceDirect+1ScienceDirectWeight-bearing timing after the operative management of ankle fractures: Single center audit and critical appraisal of literature - ScienceDirectScienceDirectEarly Weight Bearing Is Not Associated with Short-Term Complications in ...

After nonoperative treatment or ORIF, compare serial radiographs for maintenance of mortise congruity and fixation position, and examine the incision or fracture blisters for wound dehiscence or infection. Escalate new deformity, worsening pain, neurovascular change, or radiographic displacement to the operating surgeon because these findings may represent loss of reduction or fixation failure.

Persistent pain, instability, or limited recovery after apparently healed fracture should trigger a focused reassessment for syndesmotic injury, osteochondral injury, tendon injury, or post-traumatic arthritis. MRI is the most sensitive modality for ligamentous tears, syndesmotic injuries, osteochondral defects, and tendon involvement when those diagnoses remain clinically plausible. PubMedPubMedAcute Ankle Sprain - StatPearls - NCBI Bookshelf

Functional recovery is not synonymous with radiographic union. Stable nonoperative fractures may approach baseline function by 6 to 8 weeks, whereas unstable injuries requiring ORIF may recover more slowly because of greater tissue injury and immobilization; monitor return to walking, range of motion, and work-related function alongside imaging. PubMedPubMedAnkle Fracture - StatPearls - NCBI Bookshelf