Does a tri-malleolar fracture that will be operative require reduction and splinting in the Emergency Department (ED) before discharge or is a splint alone adequate?

Management of Trimalleolar Fractures in the Emergency Department

For trimalleolar fractures that will undergo operative fixation, splinting alone in the position found is adequate for ED discharge—formal reduction is not necessary unless there is neurovascular compromise. 1

Key Management Principles

Immediate Assessment Priorities

• Check neurovascular status immediately: If the extremity is blue, purple, or pale, this indicates potential limb-threatening vascular compromise requiring immediate intervention before discharge 1
• Assess for open fracture: Any open wound associated with the fracture requires covering with a clean dressing to reduce contamination and infection risk 1
• Evaluate for compartment syndrome risk: Trimalleolar fractures carry significant risk for compartment syndrome if not properly managed 2

Splinting Approach

Apply a well-padded splint in the position found without attempting reduction 1. The 2024 AHA/Red Cross guidelines explicitly state it is reasonable to treat deformed fractured extremities in the position found unless straightening is necessary to facilitate safe transport 1. The 2010 guidelines go further, stating "do not move or try to straighten an injured extremity" as a Class III recommendation (harm) 1.

Rationale for splinting without reduction:

• Splinting reduces pain, prevents further injury, and facilitates transport to definitive care 1
• There is no evidence that straightening angulated fractures shortens healing time or reduces pain prior to permanent fixation 1
• Attempting reduction carries risks of neurovascular injury 1
• Trimalleolar fractures are inherently unstable and will require surgical fixation regardless 2

Critical Exception: Neurovascular Compromise

If the extremity shows signs of vascular compromise (blue, pale, pulseless), activate EMS/orthopedics immediately 1. In this specific scenario, gentle realignment may be necessary to restore perfusion while awaiting definitive care, but this should ideally be performed by or in consultation with orthopedics 1.

Discharge Instructions

• Strict non-weight bearing until orthopedic evaluation 1, 2
• Elevation and ice application (20-minute intervals, 3-4 times daily with barrier between ice and skin) 1
• Urgent orthopedic follow-up within 24-48 hours, as these fractures almost always require surgical repair 2
• Return precautions for increasing pain, numbness, tingling, color changes, or inability to move toes 1

Common Pitfalls to Avoid

• Do not attempt closed reduction in the ED unless there is documented neurovascular compromise that cannot wait for orthopedic consultation 1
• Avoid overtight splinting: Ensure adequate padding and monitor for compartment syndrome symptoms 1
• Do not delay orthopedic referral: Trimalleolar fractures are unstable injuries requiring surgical fixation; conservative management leads to significant morbidity including arthritis, malunion, and loss of mobility 2, 3