Introduction

Overview of ankle fractures in the elderly

Trimalleolar fractures, also known as ankle fractures, are one of the most common injuries experienced in elderly patients. In most cases, it is caused by playing sports, falling, tripping, abruptly, rolling or rotating your ankle.¹

Around 74 per 100,000 elderly patients, over the age of 60 years, have ankle fractures, with 12% of mortality for those over the age of 65 years, in 1 year. It is believed this number will double by the year 2050.^2,3

Since elderly patients are more prone to osteoporosis and comorbidities, having ankle fractues can worsen the symptoms, because it can have a long-term effect on your quality of life, as it may affect your ability to walk.  

Pathophysiology and risk factors

Mechanism of injury for trimalleolar fractures

A trimalleolar fracture means three bony parts at the end of the lower leg bones are broken.

• The tibia (shinbone) is the larger bone in your lower leg. Medial malleolus, which is the bony knob that sticks out at the inside of the ankle and the posterior malleolus, which is the bony section at the back of the tibia
• The fibula is a smaller bone in the lower leg and the lateral malleolus, which is the knob that comes out on the outside of the ankle

All these structures form the malleolus complex, and they create a three-sided frame supporting ligaments that keep the ankle stable and allow movement of the ankle and foot. Having the fracture destroys and changes the support and the stability of movement.²

Age-related risk factors

Risk factors for ankle fractures in the elderly include:^3,4

• Osteoporosis
• Decreased bone density
• Diabetes
• Arthritis
• Decreased muscle strength
• Decreased balance and proprioception
• Peripheral vascular disease

Challenges in diagnosis and evaluation

Clinical presentation

Symptoms 

Symptoms of trimalleolar fracture include:^1,4

• Sudden pain
• Swelling
• Inability to bear the weight
• Bruising on or around the ankle
• Walking
• Deformity

Imaging modalities

For the doctor to better understand the extent of the fracture and to better  look at your ankle, they may need to provide some tests, such as:¹

• X-rays
• CT scans
• MRI
• Arthroscopy

These tests can help the doctor plan a suitable treatment for you.

Treatment approaches and challenges

There are several ways to treat an ankle fracture, The most common treatment is surgery; however, your doctor will recommend what is best for you.^1,4,5

Surgical management

Surgery is the most effective option to restore your ankle.

 It may help to stabilise the joints and will help with movement. Some of the common procedures carried out are:

• Open reduction internal fixation. (ORIF)
• Posterior malleolus fixation.

Non-surgical management

If surgery is not an option, your doctor may recommend conservative non-surgical treatment, especially for those with severe comorbidities or poor overall health.

. With conservative methods, you may not be able to properly treat the fracture, which may still affect your daily life. 

Age-specific surgical challenges

In the elderly, there are a lot of measures that should be considered before surgery, including:

• Pain, because of poor bone quality for fixation
• Infections
• Healing the wound may take longer
• Deep vein thrombosis

Post-treatment considerations 

Rehabilitation challenges

Physical therapy is essential to restore mobility and reduce the risk of future falls. While recovery from an ankle fracture can take time, therapy significantly aids the healing process.. However, it is important to consider that it can take time, especially in the elderly, due to weakness.⁵

Emerging strategies and future directions

Advances in surgical techniques and materials

Recently, with advancements in technology and emerging treatments, minimally invasive intramedullary nail implantation is used for unstable fibula fractures. This new technique reduces the risk of damaging soft tissues, but it might not be reliable in the reconstruction of the bones.⁶

Summary

Trimalleolar fractures are one of the most common types of fractures in the elderly and can be a very complicated and serious type of injury. Surgery is the main type of treatment that is done, but it may require more than one surgery to repair each broken bone, and with that, damage to tendons and ligaments can also be apparent, adding more time to recovery.  Ankle fractures can also affect your quality of life, as you may be unable to do your daily tasks. Speak to a doctor if you have recently fallen or feel pain in your ankle.