Ankle > Ankle Fractures > Treatments

    Open Reduction, Internal Fixation

Treatment Introduction

Most severe ankle fractures are surgically stabilized using plates and screws to ensure your broken bones heal in the proper position. Severe ankle fractures involve complete cracks in your bones and displacement of the bones into improper positions. Fractures in the base of your shinbone (tibia) and your smaller lower leg bone (fibula) can be highly unstable, especially when the bones shift position. Fractures that occur with damage to one of the main ligaments providing support for your ankle, called the deltoid ligament, typically are considered unstable injuries and require surgery. Your physician typically needs to make an open incision and reconstruct the bones in your ankle to properly treat a major ankle fracture.

Preparing for Surgery

Though you may not have much time between suffering an ankle fracture and undergoing surgery, the actions you take before surgery can be every bit as important as the procedure itself in ensuring a healthy recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   To understand the potential risks and benefits of the surgery, ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

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At most medical centers, you will go to "patient admissions" to check in for your operation. There may be separate check-in areas for ambulatory outpatients (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or an assistant about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your ankle area may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or an assistant and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). An IV (intravenous) line may be inserted into your arm at this time. Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your short leg cast or splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.


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Open reduction and internal fixation of your ankle fracture can take between two and three hours to perform, depending on the different bones your surgeon needs to fix in place with screws, pins, or plates. Spinal anesthesia typically is given to numb you from the waist down, and you usually are sedated so you sleep through the procedure.

   Your surgeon may have to make multiple incisions. Exposing your small lower leg bone (fibula) usually requires a straight lateral incision about ten to 12 centimeters long made on the back and outside of your ankle. Usually a smaller incision, about five to six centimeters, is made on the inside part of your ankle to allow access to the bony knob (medial malleolus).

   The bone most commonly fractured is the lower portion of your fibula. Your surgeon typically fixes your broken fibula with a plate and screws.

   The bony knob (medial malleolus) on the inside of your ankle can be fractured as well. Screws or wires are used to anchor the fractured portion to the rest of your shinbone.

   Similar fixation is used on any other areas that may be fractured in your ankle.

   If the fractured bones broke the skin, the wound will be washed out and some of the damaged tissue may need to be cut away before your incisions are closed with stitches. A splint is applied to immobilize your ankle, and you are taken to the recovery room.

After surgery to stabilize your fractured ankle, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia wear off. Your ankle will be immobilized in a splint when you wake up, and your ankle will be elevated. The post-surgery ankle splints usually are made of a "U-shaped" plaster splint on the inside and outside of your ankle that wraps around your heel. It immobilizes your ankle, but it can be removed more easily than a short leg cast. You will not be able to see the two incisions wrapped in the splint, but there usually is minimal bleeding after surgery. Surgical repair of your anklebones can cause a substantial amount of pain. Adequate pain medications will be prescribed for you. You ordinarily are hooked up to an intravenous (IV) patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Some patients may be prescribed oral or intramuscular pain medications. You usually can have visitors about a half-hour after surgery if your physician feels you are in a stable condition. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of the doctor, will determine when you are ready to leave the recovery room and be transported to the hospital ward for further post-operative care. In some cases, you may be transported to a ward for intensive care or heart monitoring if you have special post-operative medical needs. Most patients spend one to two days in the hospital before going home.

After surgical repair of a fractured ankle, most healthy patients remain in the hospital from one to two days. However, some patients may require a longer stay in the hospital due to pre-existing medical problems or medical issues that may arise after surgery. There are small risks of infection after major ankle surgery, but there is not much you can do to prevent infection because you cannot remove your splint. Your physician should check your incision before you leave the hospital and then again after 10 to 14 days so that he can treat any rare incision problems. Each patient is different and may have different criteria for being able to go home. In general, the length of your hospital stay is based on the amount of pain management you need. You will receive fluids and medications, through an intravenous (IV) line until you can drink an adequate amount of fluids without nausea or vomiting. Most patients can drink something the night after surgery and eat something more substantial the following morning. Be sure to ask for pain medications as soon as you feel pain coming on, because medications are most effective on pain that is building rather than on pain that is already present. Your nurses will not give you more than your doctor has prescribed and what is considered to be safe. Physicians prescribe crutches to help you move around without putting weight on your ankle. The day after surgery, you typically meet a physical therapist who teaches you about using crutches and helps you walk around the hospital using them. You will likely be unable to bear weight on your ankle for six to eight weeks after surgery. Your physician may obtain X-rays of your heel and ankle before you leave the hospital. You should arrange for someone to drive you home when you are discharged.

For four to five days after surgery to repair your fractured ankle, you should stay off your feet, elevate your ankle above heart level, and move around the house as little as possible. Crutches usually are prescribed for about eight weeks so you can keep your body weight off your ankle. Rest as much as possible with your ankle elevated to help blood drain away from your ankle and control swelling. The more weight you put on your ankle, the greater your chances of disrupting the healing process in your anklebones. Household tasks that require you to be on your feet may be difficult for eight weeks. It can be helpful to have someone around the house to help with any physical chores. You will be instructed to return to your physician’s office for regular check-ups after surgery. The dressing covering your wound inside your post-surgery ankle splint usually does not need to be changed until the splint is removed 10 to 14 days after surgery. A typical follow-up schedule after you leave the hospital may go as follows:

   Ten to 14 days – Stitches are removed and your ankle is put into a short leg cast.

   Two weeks later – Return for a check-up. Possibly receive X-rays and if necessary, a new cast. For the next six to eight weeks, you may return for a check-up every two weeks.

   Eight weeks after surgery – The cast is removed and you receive a removable brace called a cam walker or an air cast that can be worn inside your shoe. When the cast comes off, you usually can start bearing weight on your ankle, but you may continue using crutches or a cane if your ankle hurts or feels weak. Your physician or physical therapist teaches you the basic stretching and range of motion exercises you can perform at home.

Depending on how well you are able to strengthen your own ankle, your physician may prescribe physical therapy to help you regain mobility.

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Eight weeks after surgery to repair your fractured ankle, you usually are able to perform daily range-of-motion exercises while wearing a cam walker or air cast. Ankle stretching exercises should usually be done for about four weeks prior to using weights to strengthen your ankle. Depending on the extent of damage in your ankle, you may lose some of the range of motion that you had before the fracture. Your ankle may feel stiff at first, but the pain should go away as you rebuild your strength. Everyone heals at a different rate and you should begin exercises slowly until your pain has decreased. Your repaired bones of your ankle should be stable before you put stress on your ankle with walking, running, and other exercise. Physical therapy usually involves learning an ankle stretching routine and performing ankle strengthening exercises. Once your bones have healed and your strength is equal in both ankles, you may be able to return to any sports and activities that you participated in before the fracture. This can take from four to six months after surgery. As you improve muscular strength, the final phase is proprioceptive training, in which you stand on balancing boards to assist training your leg muscles to stabilize the foot and ankle.

Once your fractured ankle has healed, the bone should be just as strong as it was before the fracture. To prevent reinjury, you should strengthen the muscles and tendons around your ankle. Appropriate strength training, which focuses on the peroneal muscles of the lower leg, and conditioning for the sports you play are important preventive measures. Athletes should use up-to-date equipment. To prevent ankle fractures, you should try to play on good, level fields, courts, or tracks. If your ankles are already weak, avoid playing on uneven surfaces. Another preventive technique is choosing the right footwear. Proper fit, support, and design for specific sports should be taken into consideration. Some shoes have built-in medial and lateral supports, which may assist in preventing injury. Soccer shin-guards with circular pads on the bony sides of the ankles may prevent direct bruise or trauma to the bone. Hockey players should wear extra ankle padding to help avoid injury from sticks and skate blades. Adding calcium supplements to the diet may help women with osteoporosis strengthen their ankle bones. If your ankle starts to hurt during exercise, you should return to your physician’s office for a check-up.