Overview

Trimalleolar fracture is the least common type of ankle fracture and occurs when you break the lower leg sections that form the ankle joint.¹ trimalleolar fracture is referred to as a three-part fracture and is a result of breaking three bony sections at the end of the lower leg, including the medial malleolus, posterior malleolus and lateral malleolus.^1,2 The medial malleolus is a bony knob that sticks out at the inside of your ankle.¹ The posterior malleolus is a bony section at the back of your tibia (shinbone).¹ The lateral malleolus is a bony knob that sticks out on the outside of your ankle.¹ Therefore, a trimalleolar fracture is a fracture of all three malleolus bones. 

This article will focus on different rehabilitation strategies for restoring ankle function after a trimalleolar fracture and explore the importance and effectiveness of rehabilitation. 

Causes

The causes of a trimalleolar fracture can reflect the causes of a typical ankle fracture and may include, but are not limited to:^1,3

• Falls
• Tripping
• Playing sports
• Road traffic accidents 

In addition to physical trauma resulting in a trimalleolar fracture, individuals who are at greater risk for a trimalleolar fracture include:^1,4

• Elderly (65+ years old)
• Underlying conditions (osteoporosis)
• Smoking 

Symptoms

The symptoms of a trimalleolar fracture also generally reflect the symptoms of a typical ankle fracture and may include:¹

• Bruising on or around the ankle
• Swelling
• Inability to place weight/walk on your ankle
• Sudden severe pain 

Walking with a trimalleolar fracture can be difficult and painful, and can result in further injuries. 

Diagnosis 

To determine whether an individual has a trimalleolar fracture, a healthcare provider may use the following tests, such as:¹

• X-ray
• Computed tomography scan
• Magnetic resonance imaging
• Arthroscopy 

Treatments for a trimalleolar fracture include ankle surgery and physical therapy. Most commonly, open reduction internal fixation (ORIF) surgery is used, which aims to line up broken bones so they can heal appropriately.¹ 

What is rehabilitation?

As defined by WHO, rehabilitation is a set of interventions created to optimise functioning and reduce disability in patients with health conditions in interaction with their environment.⁵ Rehabilitation is extremely important in a condition such as recovery after a trimalleolar fracture, where day-to-day activities have become difficult due to injury. Rehabilitation works to improve the quality of life and function of an affected individual and allows them to regain a sense of control over how their life functions. 

A trimalleolar fracture can have long-term effects and can affect the quality of life of an individual:¹

• Increases likelihood of developing arthritis in your ankle
• Sustained damage to tendons and ligaments increasing recovery time
• Walking with a limp after recovery
• Requiring a brace
• Requiring ankle surgery 

Thus, rehabilitation after a trimalleolar fracture is important in allowing for improved outcomes and reducing the long-term impacts of the injury. We will now discuss the types of rehabilitation used for a trimalleolar fracture and their purposes.

Rehabilitation for a trimalleolar fracture

Multiple different strategies for trimalleolar fracture rehabilitation exist, with all aiming to improve ankle stability, restore function, reduce pain and increase mobility/flexibility. Rehabilitation starts after surgery to repair the trimalleolar fracture. Examples of rehabilitation used post-operatively in the case of a trimalleolar fracture include:⁵ 

• Cryotherapy—to reduce swelling
• Isometric exercises of the leg muscles—to improve muscular strength of lower limbs
• Balance retraining—to achieve equilibrium
• Stretching technique—to improve flexibility
• Ultrasound—to improve scar tissue 

After surgery, your doctor will place you on a rehabilitation plan, which includes a variety of exercises to be carried out over a period of either a few weeks to months. The intensity of these exercises can increase/decrease throughout this period of time. Exercises are created in a way that can be easily carried out at home, and you may be provided with bands for further support. 

We will now discuss the use of the above rehabilitation strategies and how they create improvements.

Cryotherapy

Cryotherapy is the application of “cold” for the treatment of disease or injury.⁷ Types of cold treatment include ice packs, ice towels, gel packs, and ice massages.⁸ Cryotherapy is generally used for sports-related injuries, but can also be seen being used as part of a rehabilitation programme to reduce recovery time.⁸ Furthermore, cryotherapy has been shown to reduce pain effectively after the reconstructive surgery of joints.⁸ Thus, cryotherapy can be seen as a significant factor, helping reduce both pain and recovery time in postoperative patients of a trimalleolar fracture. 

Isometric exercises

Isometric exercises are defined as contractions of a specific muscle or group of muscles.⁹ Isometric exercises can be used to strengthen muscles in specific joint positions, allowing you to both strengthen your muscles and protect your joints after surgery.¹⁰ As a trimalleolar fracture can have long-term effects such as limping, isometric exercises can help reduce and even prevent limping from occurring, allowing for an improved quality of life. 

Balance retraining

Balance retraining is a form of therapy that aims to improve balance and reduce changes caused as a result of injury or disability. Trimalleolar fracture can result in ankle instability and an inability to walk steadily; thus, balance retraining is important in allowing a patient to regain their ability to walk steadily. Many forms of balance exercises exist, such as:¹¹

• Sideways walking
• Simple grapevine
• Heel-to-toe walk
• One-leg stand
• Step up 

These exercises exist to improve a patient's current balance and overall mobility. ¹¹ Regaining equilibrium is important for patients with trimalleolar fractures to improve the recovery process and reduce the likelihood of developing a limp.  

Stretching

The purpose of stretching as a form of rehabilitation post-trimalleolar fracture surgery is to restore and maintain flexibility, improve range of motion, reduce stiffness, and prevent further injury.¹² Similarly to balance retraining, multiple ankle support stretches exist, which include:¹³

• Ankle bend
• Ankle tilt
• Seated heel raise
• Standing double heel raises
• Standing calf stretch 

In addition, stretching exercises can also focus on specific bending of the foot known as dorsiflexion and plantar flexion. The purpose of focusing on these moments is to improve recovery of ankle mobility in addition to preventing further secondary consequences such as deep vein thrombosis.¹⁴ 

Ultrasound

Ultrasound can be used in therapy to promote healing, reduce pain and increase tissue flexibility.¹⁵ Surgery to repair trimalleolar fractures includes creating incisions, which results in the creation of scars and scar tissue. Ultrasound can be used as a rehabilitation therapy to help both reduce the appearance of scars, but also increase their extensibility, thus preventing scar tissue from limiting the range of motion available within these individuals.

Limitations of rehabilitation strategies 

Though rehabilitation strategies bring the promise of improved quality of life and recovery, there are many limitations associated with rehabilitation strategies:^16,17,18

• Patient adherence
• Specificity of the programme
• Fear of reinjury 
• Resource and infrastructure limitations 

It is important to discuss any fears regarding your rehabilitation programme with your doctor to ensure the best programme can be curated towards your needs. 

Summary

Rehabilitation strategies are crucial in allowing for the restoration of ankle function in patients with trimalleolar fractures. The focus on joint and muscle strengthening both prevents further injury and allows a return to normal. Key rehabilitation methods include cryotherapy to reduce swelling and pain, isometric exercises to strengthen muscles and prevent limping, balance retraining to improve stability and walking ability, and stretching to restore flexibility and prevent stiffness. Ultrasound therapy also aids in softening scar tissue and enhancing tissue flexibility. Effective rehabilitation relies on patient adherence to prescribed exercises, which are typically performed over weeks to months. However, limitations such as fear of reinjury, lack of resources, and programme specificity can impact outcomes. Open communication with healthcare providers ensures tailored rehabilitation plans that address individual needs and concerns. Successful rehabilitation significantly enhances recovery, reduces long-term complications, and improves overall quality of life after a trimalleolar fracture.