If open surgery is planned, the ankle should be splinted and elevated to allow resolution of soft tissue swelling and blistering. Premature surgery is associated with an increased risk of wound complications.
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.
In elderly osteoporotic patients fixation is difficult (though Makwana’s series suggests it is worth trying). Fibular nails have been described but their place is not yet clear.
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). For further details see the page on medial malleolar fractures.
See the pages on posterior malleolar fractures and syndesmotic injuries for discussion of relevant issues.
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