Most ankle fractures are isolated malleolar, but bimalleolar and trimalleolar occur in up to one-third. While there are numerous classification systems, the simplest is based on the radiographic appearance of these malleoli.
Essential treatment is directed at stability and exclusion of associated injuries. Neurovascular status (deep peroneal, superficial peroneal, medial and lateral plantar nerves, posterior tibial artery, and dorsalis pedis artery) should be assessed. The entire length of the fibula, including the proximal portion should be palpated to rule out additional fractures. All ankle fractures, with the exception of fibular avulsions, require immobilization by cast, or reduction followed by casting. With the exception of unimalleolar fractures, most require open reduction and fixation, thus orthopedic consultation is recommended. In the ED, fractures should be splinted with a posterior mold, kept non–weight bearing, elevated, and iced for 24 hours. Appropriate analgesia and consultation is addressed. The overall goal is to restore anatomic relationships, maintain them during healing, and institute early mobilization. Complications, although rare, include skin necrosis, osteomyelitis, osteoarthritis, and malunion.