Ankle Fractures
Stability, syndesmosis, and fixation sequence.
Aug 15, 2026 · 3 refs
At a glance
Ankle fracture care is stability care. The question is whether the talus will stay reduced under the plafond through healing — not merely which malleoli are broken.
Read the mortise, stress when uncertain, and respect soft tissue. A perfect plate on a blistered ankle is the wrong win.
Classification
- Weber / Danis–Weber — fibula level relative to syndesmosis (A below, B at, C above)
- Lauge-Hansen — mechanism language useful for associated injuries
- Bimalleolar / trimalleolar / equivalents (deltoid incompetence can behave like a bimalleolar injury)
Decision-making
Stable, minimally displaced unimalleolar patterns may be non-op with close follow-up. Any suggestion of talar shift, unstable bimalleolar pattern, or syndesmotic instability pushes toward operative restoration of the mortise.
Reduce dislocations urgently. Temporary spanning external fixation belongs in the soft-tissue damage-control toolkit when the skin will not tolerate early ORIF.
Treatment
- Restore length, rotation, and alignment of the fibula; address medial clear space / deltoid as needed
- Fix the posterior malleolus when it contributes to stability or articular congruence
- Stress the syndesmosis after malleolar fixation; stabilize if incompetent
- Protect soft tissue; delay definitive fixation when blisters or massive swelling demand it
High-yield / exam
- Stability > number of malleoli
- Medial clear space and talar shift matter
- Syndesmosis testing after bony fixation
- Soft-tissue timing prevents wound disaster
Questions
On call and Boards items for this topic are coming.
Open the bank →Your pearl
One line you’d tell a junior at 2am.
References
- 01
Ankle fractures resulting from rotational injuries
Michelson JD · 1995 · Journal of the American Academy of Orthopaedic Surgeons · review
Frames ankle fractures as rotational stability problems.
- 02
Management of syndesmotic ankle injuries
2007 · Journal of the American Academy of Orthopaedic Surgeons · review
Syndesmotic competence is part of every unstable ankle plan.
- 03
OTA teaching resources on ankle fracture stability and fixation sequence
2020 · Orthopaedic Trauma Association · guideline
Emphasizes mortise restoration and soft-tissue timing.
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