Ankle Splinting Position for Trimalleolar Fractures
For trimalleolar fractures, the ankle should be splinted in neutral position (90 degrees) to minimize soft tissue complications and facilitate subsequent surgical management.
Splinting Approach Based on Current Guidelines
The most recent first aid guidelines emphasize splinting fractured extremities in the position found rather than attempting to manipulate them into a specific position 1. It is reasonable to treat a deformed fractured extremity in the position found unless straightening is necessary to facilitate safe transport 1.
Key Principles for Trimalleolar Fracture Splinting:
Splint in the position found - The 2024 American Heart Association and American Red Cross guidelines recommend treating deformed fractures in their presenting position to avoid neurovascular injury 1
Neutral position is preferred when achievable - If the ankle can be positioned comfortably, neutral (90 degrees) is the standard position as it:
- Minimizes tension on neurovascular structures
- Prevents equinus contracture that occurs with plantarflexion
- Facilitates subsequent surgical planning 2
Avoid forced manipulation - Do not attempt to straighten an angulated fracture unless absolutely necessary for transport, as this risks nerve injury and vascular compromise 1
Critical Assessment Before Splinting:
Check for vascular compromise immediately - If the extremity is blue, purple, or pale, activate emergency services immediately as this indicates limb-threatening injury 1
Assess neurovascular status - Document pulses, capillary refill, and sensation before and after splint application
Cover open wounds - If the fracture is open, cover with a clean dressing to reduce contamination risk before splinting 1
Why Neutral Position When Possible:
While the guidelines don't specify exact ankle positioning for trimalleolar fractures specifically, neutral position is preferred in clinical practice because:
Plantarflexion should be avoided - This position increases posterior displacement of the talus and can worsen posterior malleolar fragment displacement, which is critical since these fractures are inherently unstable 2
Dorsiflexion creates excessive tension - This can compromise anterior neurovascular structures and increase soft tissue swelling
Neutral maintains anatomic relationships - This position best preserves the mortise alignment until definitive surgical fixation can be performed 2
Common Pitfalls to Avoid:
Do not force the ankle into any specific position if significant resistance or deformity is present 1
Do not delay transport attempting to achieve perfect positioning - splinting is primarily to reduce pain and prevent further injury during transport 1
Do not apply excessive padding that could mask developing compartment syndrome
Monitor for compartment syndrome - These are high-energy injuries with significant soft tissue trauma
Definitive Management Context:
Understanding that trimalleolar fractures with any displacement require surgical fixation 2, the initial splinting position is temporary. These fractures are inherently unstable and require operative intervention 2, so the splint serves only to stabilize during transport to definitive care where open reduction and internal fixation will be performed 2, 3, 4.