What to Know About a Trimalleolar Ankle Fracture

Medically Reviewed by Poonam Sachdev on October 26, 2021
4 min read

A trimalleolar ankle fracture is when your ankle breaks in three separate places. Only 7% of all ankle breaks are trimalleolar ankle fractures. They are rare, and they are among the worst kinds of ankle fractures.

Your ankle is an important weight-bearing joint. It’s made of three bones that are attached to each other with many ligaments — a type of connective tissue. The bones of the ankle joint include the: 

  • Tibia: a leg bone, also known as the shinbone
  • Fibula: a thinner leg bone next to the tibia
  • Talus: a smaller bone between the two leg bones in the joint, with the heel bone beneath it

In a trimalleolar ankle fracture, your ankle joint is broken in three places: 

  • Lateral malleolus: the lower part of the fibula, near the ankle joint 
  • Medial malleolus: the inner part of the lower tibia, near the ankle joint
  • Posterior malleolus: the back part of the tibia, right at the level of the ankle joint

Your ligaments may also be damaged from the injury. 

Many ankle fractures have common causes, including rolling or twisting your ankle, falling, or injuries from a vehicular accident or sports activity.

To get a trimalleolar fracture, the impact has to be very hard or from a particular angle to lead to this amount of damage. 

Women ages 75 to 84  most commonly get trimalleolar ankle fractures because they fall more. Young and middle-aged men who get hit or land with a lot of force while doing an activity are the second most common group. 

The symptoms of a trimalleolar ankle fracture will be similar to those of other kinds of broken ankles. Sometimes very severe ankle sprains can also look like broken ankles. For this reason, it’s important to see your doctor when you believe that you have seriously injured your ankle.

Your doctor will be able to figure out your exact type of injury by looking at it with an X-ray or magnetic resonance imaging (MRI), which can show damage to ligaments.  

Common symptoms of a broken ankle include: 

  • Pain 
  • Swelling
  • Bruising
  • Unable to support all of your weight, or any weight
  • Unable to move in its normal range of motion
  • The joint looks like it's not lined up the right way or the bone is showing.

Yes. Almost all trimalleolar ankle fractures require surgery. The three breaks in your ankle leave the joint very unstable. ‌

Without surgery, the bones will take much longer to heal and may heal crooked. The ankle can remain quite painful, and you may lose the ability to put weight on it ever again. 

There are very few exceptions to needing surgery, even for older age groups. Exceptions are only made for people who don’t or can’t walk, or who have other health problems that make the surgery too dangerous. In this case, the ankle bones are physically moved back into place through the skin by a doctor and the ankle is put in a cast. 

You will not be able to put weight on it for around six weeks. You’ll then need a brace until your doctor says that you’re healed.

The surgery for a trimalleolar ankle fracture is a combination of the three surgeries that are done when each bone breaks individually. The three procedures are: 

For the lateral malleolus fracture. The bones are realigned and screws and metal plates are put on the outside of the bone. Sometimes screws and metal rods are also put inside of the bone to help with the healing process. 

For the medial malleolus fracture. The procedure is the same as for the lateral malleolus fracture. Bone grafts, which are transplanted bone, are sometimes used if the damage is too extreme.

For the posterior malleolus fracture. The standard treatment is to fix the bone in place using a metal plate and screws. 

Surgery for a trimalleolar ankle fracture has risks, including:

  • Infection from open wounds
  • Nerve damage
  • Scarring
  • Irritation from the supporting pieces put in during the surgery

There's also the chance that the surgery will fail or the bones will still not heal properly. In this case, the surgery will need to be repeated. 

Your recovery from this surgery will depend on your break and how successful your surgery is. The bones will take at least six weeks to heal and your doctor will want to regularly check your progress during this time. 

You’ll need to take regular X-rays until your doctor has decided that your ankle has healed enough. At this time you can begin to put weight on your ankle, usually with a brace. You may also need physical therapy at some point during your healing process.