Clinical outcomes following staged management of bimalleolar and trimalleolar ankle fractures

Ankle fractures are among the most common lower extremity fracture types with an incidence rate of 4.22/10,000 person-year, but guidelines for preliminary stabilization remain limited. Currently, few studies compare both splinting and external fixations to how they affect postoperative complications.

The purpose of this study was to extend the analysis of postoperative complications to include fracture healing outcomes when comparing splinting and external fixation.

A retrospective review of 652 patients with bimalleolar and trimalleolar ankle fractures undergoing preliminary fixation with either splinting or external fixation from 2017 to 2024 was performed.

Fractures were grouped as splint (n = 493) or external fixator (n = 159), with subgroup analysis by open vs. closed fractures. Outcomes included length of stay, days to fixation, infection rates, and non-infectious complications (delayed union, malunion, nonunion, hardware failure). Additional subgroup analyses evaluated complication rates by fracture pattern.

External fixation was associated with longer hospital stays (12.2 vs 5.4 days, p < 0.001) and delayed definitive fixation (median 5 days [IQR 3-9] vs 2 days [IQR 1-5], p < 0.001). Infection rates were higher with external fixation (11% vs 6%; p = 0.031). In subgroup analysis, closed bimalleolar fractures had higher complication rates with external fixation (40%, 95% CI: 24-56) compared to splinting (11%, 95% CI: 7-16) where (p < 0.001).

Splint immobilization of ankle fractures led to shorter hospital stays and days to definitive fixation. When preliminary fixation was achieved with splinting, complication rates were significantly lower compared to external fixation.