Quadrimalleolar Fractures of the Ankle: Think 360°—A Step-by-step Guide on Evaluation and Fixation

Trimalleolar fractures, which involve the medial malleolus, lateral malleolus, and posterior malleolus, have been traditionally associated with a less favorable prognosis in ankle fractures. Less frequently, the anterolateral tibial rim ("Tillaux-Chaput tubercle") and anteromedial fibular rim ("Wagstaffe-LeFort fragment") are fractured. Trimalleolar fractures with anterior fractures are named quadrimalleolar fractures. Only correct planning will lead us to a good result. A 360 view is needed to plan appropriate treatment for fractures including the anterior and posterior tibial rim. CT scanning is essential. The ankle is divided into four areas on the axial CT scan: (A) (posterior malleolus), (B) (medial malleolus), (C) (lateral malleolus), and (D) (anterior malleolus Chaput and/or Wagstaffe fragments). Depending on which malleolus is involved, different approaches and ways of fixing the fractures have been described. At the end of the procedure, after performing open reduction and internal fixation of all four malleoli, syndesmotic stability must be tested intraoperatively. Patients with complex malleolar fractures are kept with a walker boot for 15-21 days after surgery with sole contact (max. 20 kg), to avoid subsequent retraction and forced plantar flexion of the ankle. Early walking as tolerated with two crutches at week 4. In the fifth week, we are authorized to weight bear 50% (one crutch) and in the sixth week full weight-bearing. These periods are prolonged with osteoporosis, plafond impaction, or poor patient compliance.