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

Complex trimalleolar ankle fractures are a major orthopaedic challenge, with an incidence of 4.22 per 10000 person-years in the United States and an annual cost of 3.4 billion dollars. This review synthesizes current evidence on diagnostic protocols and management strategies, highlighting optimal approaches and emerging trends. Initial care emphasizes soft tissue assessment, often guided by the Tscherne classification, and fracture classification systems. External fixation may be required in open injuries, while early open reduction and internal fixation within six days is linked to improved outcomes. Minimally invasive techniques for the lateral malleolus, including intramedullary nailing and locking plates, are effective, while medial malleolus fractures are commonly managed with screw fixation or tension-band wiring. Posterior malleolus fragments involving more than 25% of the articular surface usually warrant fixation. Alternatives to syndesmotic screws, such as cortical buttons or high-strength sutures, reduce the need for secondary procedures. Arthroscopic-assisted open reduction and internal fixation benefits younger, active patients by enabling concurrent management of intra-articular and ligamentous injuries. Postoperative care prioritizes early weight-bearing and validated functional scores. Despite advances, complications remain common, and further research is needed to refine surgical strategies and improve outcomes.