Trimalleolar Fracture

Trimalleolar fractures are the least common ankle fracture. A trimalleolar fracture happens when you break your lower leg sections that form your ankle joint and help you move your foot and ankle. Treatment includes surgery and extensive physical therapy. A trimalleolar fracture can have long-term impact on your quality of life.


What is a trimalleolar fracture?

Trimalleolar fractures happen when you break the lower leg sections that form your ankle joint and help you move your foot and ankle. Trimalleolar fractures require surgery and extensive physical therapy. A trimalleolar fracture can have a long-term impact on your quality of life.


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What happens when I have a trimalleolar fracture?

When you have a trimalleolar fracture, you've broken three bony sections at the end of your lower leg bones:

  • Your tibia (shinbone). This is the larger bone in your lower leg. There's a bony knob that sticks out at the inside of your ankle. This is your medial malleolus. There's also a bony section at the back of your tibia. This is your posterior malleolus.
  • Your fibula. This is the smaller bone in your lower leg. There's a bony knob that sticks out on the outside of your ankle. This is your lateral malleolus.

The bony sections, which are sometimes called the malleo complex, create a three-sided frame supporting the ligaments that keep your ankle stable and let you move your ankle and foot.

Is a trimalleolar fracture a serious injury?

A trimalleolar fracture is a serious injury that can affect your quality of life and cause long term problems:

  • You'll need ankle surgery to repair your trimalleolar fracture.
  • You'll be in a cast or a brace or brace while your ankle heals. It can take months to recover from a trimalleolar fracture. That means you won't be able to get around easily, drive, or do other everyday activities.
  • You can damage the tendons and ligaments that support your broken bones, adding to the time it takes to recover.
  • You might walk with a limp even after your fracture heals.
  • You are likely to develop arthritis in your ankle.


What causes a trimalleolar fracture?

Trimalleolar fractures can have several causes:

  • Motor vehicle accidents.
  • Falls.
  • Playing sports.
  • Tripping.
  • Abruptly "rolling" or rotating your ankle.

Who is likely to have a trimalleolar fracture?

Historically, adults ages 65 and older are most commonly treated for trimalleolar fractures after tripping and falling. Younger people are injured playing sports, being in motor vehicle accidents or falling.

As older adults remain active longer, healthcare providers are treating more trimalleolar fractures from sports injuries, motor vehicle accidents and falls from heights.


What is the difference between a trimalleolar fracture and a bimalleolar fracture?

A bimalleolar fracture happens when you break your bony knobs that stick out from the inside and outside of your ankle. These bony knobs are your medial malleolus and your lateral malleolus.

Symptoms and Causes

What are the symptoms of a trimalleolar fracture?

Trimalleolar fracture symptoms include:

  • Sudden severe pain.
  • Difficulty or inability to put weight on your ankle or walk using your ankle.
  • Bruising on or around your ankle.
  • Swelling that can be severe.

Can I walk with a trimalleolar fracture?

Trying to walk with a trimalleolar fracture would be very painful and might damage your ankle ligaments and tendons.

Diagnosis and Tests

How do healthcare providers diagnose trimalleolar fractures?

Healthcare providers use the following tests to diagnose trimalleolar fractures:

Management and Treatment

How do healthcare providers treat trimalleolar fractures?

You’ll receive medicine for pain. Trimalleolar fractures are treated with ankle surgery and physical therapy. Most trimalleolar fractures are treated with Open Reduction Internal Fixation (ORIF) surgery. The goal of ORIF surgery is to line up your broken bones so they heal appropriately.

What happens before ORIF surgery?

You'll receive general anesthesia. To prepare for general anesthesia, you should:

  • Avoid eating and drinking for eight hours before you go to the hospital unless directed otherwise.
  • If you smoke, quit smoking at least two weeks before your surgery to improve your heart and lung health. Even quitting for one day before your surgery helps your heart and lungs.
  • Stop taking herbal supplements for one to two weeks before the procedure as directed by your provider.
  • Stop taking Viagra® or other medications for erectile dysfunction for at least 24 hours before the procedure.
  • If you take certain (but not all) blood pressure medications, talk to your healthcare provider about taking your medication with a sip of water.

What happens during ORIF surgery for trimalleolar fracture?

  • Your surgeon makes incisions to open your lower leg so they can access your broken ankle bones.
  • They line up your ankle's broken pieces. This is called reduction.
  • Your surgeon then uses tools such as metal plates, screws or wires to connect your ankle's broken pieces. This is called internal fixation.
  • They close the incision.
  • Your surgeon will put your ankle in a cast or brace.

Do surgeons have to go through this process with each bone that is broken in a trimalleolar fracture?

Surgeons typically repair your medial malleolus, your tibia's bottom section, and your lateral malleolus, your fibula's bottom section. They might repair your malleolus, the back of your tibia, depending on the size of the fracture.

What are the complications with ORIF surgery to treat trimalleolar fracture?

Complications include:

  • Pain.
  • Osteoarthritis.
  • Infection.
  • Your bones' broken ends don't connect correctly.

Will I receive pain medication after surgery?

Your healthcare provider will discuss your pain concerns with you and provide appropriate medication.

Will I need physical therapy after my surgery?

Physical therapy is an essential part of recovering from a trimalleolar fracture.

Outlook / Prognosis

How soon can I walk after surgery for a trimalleolar fracture?

It could be six weeks before you can put weight on your injured ankle or walk using your injured ankle. Healing from trimalleolar surgery takes time as your broken bones heal around the tools surgeons used to stabilize your bones. Be sure to talk to your healthcare provider before putting weight on your injured ankle.

How soon can I go back to work after surgery for a trimalleolar fracture?

There are several things to consider before you go back to work:

  • You need to keep your injured ankle elevated for at least two weeks after your surgery.
  • You might be taking medication for pain that could affect your ability to work.
  • It could be as long as six weeks before your injured ankle can bear weight, so you might have trouble getting around your workplace.
  • You will be in a cast or brace for several weeks after surgery.
  • Doing too much too soon might cause you to re-injure your ankle.

How soon can I start driving after surgery for a trimalleolar fracture?

It could be several months before you can drive:

  • You'll have a cast or brace that will keep you out of the driver's seat until the cast is removed or you don't need the brace. You could be in a cast or brace for up to six weeks.
  • Your ankle will feel unstable or weak for several weeks after your cast or brace is removed, making it difficult for you to drive safely.

Will I be able to play sports after trimalleolar fracture surgery?

Most people who played sports before their trimalleolar fracture can get back in the game. But it usually takes four to six months before their injured ankle is strong enough to do that without re-injuring their ankle.

How do I take care of myself?

You should plan to have help around the house for the first six weeks as you recover from your surgery:

  • You'll need to keep your injured ankle elevated for the first two weeks, and it will be four more weeks before your ankle can bear weight.
  • You'll need help with personal care such as meals, moving to and from your bed, using the bathroom and bathing.
  • You'll need help with transportation, as you won't be able to drive for several months.

What are the long-term side effects of trimalleolar fracture surgery?

Long-term side effects can include:

  • Walking with a limp for a few months after your surgery.
  • Needing additional surgery if your ankle isn't healing appropriately.

When should I see my healthcare provider?

You will have regular post-surgery checkups.

When should I go to ER?

You should seek immediate healthcare if you:

  • Show signs of infection such as fever, chills, drainage from your surgical wound or it hurts to touch your wound.
  • You've taken a fall and think you might have re-injured your ankle.

What questions should I ask my healthcare providers?

  • How serious is my injury?
  • Do I need to have surgery right away?
  • Will I need to have more than one surgery?
  • What are the surgery side effects?
  • What can you do to help with pain?
  • Will I be able to walk normally?

A note from Cleveland Clinic

Trimalleolar fractures are complicated and serious injuries. You might need more than one surgery to repair each broken bone. You might have damaged your ankle tendons and ligaments, which adds to your recovery time.

A trimalleolar fracture affects your quality of life, as you will need help with day-to-day activities until you can put weight on your ankle. (Even then, your ankle might feel wobbly or unstable because your ligaments and tendons take more time to heal than your bones.)

You might become frustrated, anxious or feel depressed as you wait for your ankle to heal. Tell your healthcare provider how you are feeling. They'll be able to recommend programs to help you manage your recovery.

Medically Reviewed

Last reviewed on 09/13/2021.

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