There are three bones that come together to form the ankle joint: the tibia, the fibula, and the talus. The tibia and fibula (lower leg bones) end in prominences called the malleoli. The malleoli create the bony prominence seen on either side of the ankle, these are called the lateral malleus and medial malleolus. A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia. There are only two malleoli, yet the term trimalleolar fracture is still used, and so it is misnomer.

  • The most common cause is trauma, which can result from falls or incidents such as traffic accidents.
  • Participation in sports or other high impact activities can also cause trimalleolar fracture
  • Trimalleolar fracture is also occurred when the ankle is either twisted or rolled, usually with an awkward or uneven step.

 

Fractures are acute injuries (occur suddenly) therefore symptoms can often be noticed immediately following injury.

  • Sharp pain, swelling, bruising, and tenderness around the ankle
  • Inability to move the ankle or foot without pain
  • Inability to weight bear on the involved leg
  • Trimalleolar fractures are unstable injuries and they can be associated with ligament damage and dislocation.

 

In the event that an individual suspects they may have trimalleolar fracture, a radiographic evaluation (X-Ray) will be essential to a proper diagnosis. A bone can fracture in different ways, causing complications or secondary conditions that your physician will look for. Conditions that can be related to trimalleolar fracture include:

  • Comminuted fracture: a bone that is broken in several pieces
  • Dislocation: a bone that is not properly aligned in the correct joint
  • Greenstick fracture: a fracture on only one side of a bone (commonly seen in children)
  • Malunion: when the bone heals in the improper position
  • Nonunion: when the ends of the broken bone do not fuse together properly
  • Growth plate injury: in children, areas at the ends of bones (near the joint) are responsible for growing the bone as the child develops. If the growth plate is injured it may affect the growth of the bone. It is essential to future development that the growth plate is realigned and heals properly.

 

Due to severity of trimalleolar fracture, surgical repair is the first option. This is typically done using open reduction and internal fixation. Pins, screws, plates or wires may be used to hold the bones properly in place. How much movement should be restricted following the fracture will depend on the severity of the break. If the patients suffered from severe health problems, or if the risk of surgery is too great, non-surgical treatment may also be recommended. Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore ankle motion. In more involved fractures, recovery can take more time. Formal therapy and compliance with an extensive home program is essential to restoring function of the ankle.

 

  • Trimalleolar fracture immobilization can have detrimental effects that can be improved through physical therapy. These effects include:
  • Joint articular cartilage softening
  • Shortening and atrophy of musculotendinous units
  • Decreased circulation
  • Loss of active and passive motion
  • Weakness

Goals for physical therapy post-fracture immobilization of the ankle are optimal loading and restoration of normal tissue relationships to improve motion, strength and the ability to perform functional activities of daily living.

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
  • Therapeutic Exercises (TE) including exercises to improve strength and performance of the ankle.
  • Neuromuscular Re-education (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example: jumping, running etc) in use of the involved lower extremity in daily activities.
  • Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the ankle and surrounding muscles and tendons.
  • Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.

 

Most fractures can be diagnosed with X-Ray studies and when necessary a CAT Scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or when the injury affects the integrity of the joint.

Prognosis

Rate of recovery and the prognosis from trimalleolar fracture will depend on a number of factors:

  • Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to heal. Patients may have residual motion and strength deficits.
  • Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually have better pre-injury tissue integrity.
  • Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
  • Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.

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