If open surgery is planned, the ankle should be splinted and elevated to allow resolution of soft tissue swelling and blistering. It is common to delay surgery until all swelling has resolved to minimise the risks of wound problems and infection. This can add to bed occupancy problems and recent series have shown that elevation at home is safe for most patients. In fact, Chou’s (2009) review found that if anything the existing literature suggested that delay in surgery, especially beyond 4 days, resulted in increased wound problems (unlike pilon and calcaneal fractures). Schepers (2013) confirmed this in a systematic review. Manoukian (2013) found that early surgery was also cost-effective.
The patient needs to understand what can be achieved by surgery, that the ankle will not be entirely normal, and the risks of wound failure, infection and nerve injury.
Surgical planning and technique is adequately covered in specialist manuals. The lateral side is normally stabilised first using lag screw and a neutralisation plate if technically possible. Fracture comminution may preclude a lag screw and the plate is then applied in bridging mode, preferably with minimal or no disturbance to the fracture site.
Osteoporotic bone poses challenges which are discussed under fractures in older patients.
The medial side is normally stabilised after the lateral side, using lag screws or tension band wiring. Occasionally one sees fractures where the fibula is so comminuted that length is difficult to establish, or the lateral soft tissues are very swollen, blistered or bruised: in such patients it may be worth reattaching the medial malleolus first (hence reattaching the deep deltoid ligament) (Limbird 1987). For further details see the page on medial malleolar fractures.