Advancements in the diagnosis and management of complex trimalleolar ankle fractures: A comprehensive review

Table 3 Suggested management pathways for trimalleolar ankle fractures under different clinical scenarios

Scenario	Recommended approach	Supporting evidence/rationale
Open fracture with significant soft tissue injury	Initial external fixation ± orthoplastic input → staged ORIF once soft tissues permit	Reduces infection/compartment risk; Illizarov frame allows early weight-bearing[35-39]
Closed fracture with marked swelling	Temporary external fixation → delayed ORIF (ideally within 6 days)	Early stabilization with lower soft-tissue complication risk[40-47]
Posterior malleolus fragment > 25% articular surface or type II/III Haraguchi	Direct posterior approach with buttress plate/antiglide fixation	Improved reduction and prevention of post-traumatic arthritis[86-93]
Elderly/osteoporotic patient with lateral malleolus fracture	Intramedullary nailing or minimally invasive locking plate	Minimizes wound complications; preserves soft tissue integrity[48-53]
Younger/high-demand patient	Arthroscopic-assisted ORIF	Allows detection/repair of intra-articular injuries, better functional outcomes[68-73]
High-grade syndesmotic injury	Cortical button or high-strength suture fixation	Restores stability, avoids need for screw removal, facilitates early rehab[64-67]
Associated deltoid ligament injury with medial instability	Deltoid ligament repair ± ORIF	Improves reduction and long-term stability; supported in athletic/complex cases[94-102]

ORIF: Open reduction and internal fixation.