Ankle fracture represents 10% of all fractures, however, bilateral trimalleolar fracture of the ankle is not commonly seen. We report a rare case of trimalleolar fracture of bilateral ankles. The injuries occur under a variety of conditions such as falls, sports, and road traffic accidents irrespective of age and sex. The simultaneous occurrence of bilateral ankle fractures presents unique rehabilitation challenges.

A 20-year-old girl came to casualty with an alleged history of falling from an approximate height of about 20 feet in December 2023. After which she sustained injuries over her both ankle joints with no history of any head injury, loss of consciousness, vomiting, seizure, or any ear, nose, or throat bleeding. She complained of bilateral ankle pain and was unable to stand. The patient had no significant medical history or previous surgeries. She denied any chronic illnesses or regular medications. On physical examination, she was conscious and well-oriented to time, place, and person. Chest and pelvic compression tests were negative. No bony deformities were noted in both the upper limbs. Her ankles were swollen, ecchymotic, and tender to palpation over the medial and lateral malleoli. Bilateral deformities were noted, with notable asymmetry. Distal neurovascular status was intact with palpable pulses and normal sensation in both lower extremities. X-rays of anteroposterior and lateral views of both ankles were obtained, revealing bilateral trimalleolar fractures. The fractures involved the medial malleolus, lateral malleolus, and posterior malleolus bilaterally (Fig. 1a, b, c, and d). For the right ankle fracture, it was classified as Lounge – Hansen type Pronation – External rotation, for the left ankle it was classified as Ruedi-Allgower type 3 pilon fracture. A computed tomography scan of both ankles was performed to further delineate the extent of the fractures and assist in surgical planning. The imaging confirmed bilateral trimalleolar fractures with displacement and comminution, more severe on the left side. Emergency department management included immobilization of both ankles with splints and administration of intravenous analgesics for pain control. The patient was admitted for surgical management due to the complexity and bilateral nature of the fractures. The patient underwent bilateral open reduction and internal fixation of the ankle fractures. The procedures were performed sequentially. It was a staged procedure, starting with the more severely injured left ankle followed by the right ankle after 2 days. For the right ankle the posterior malleolus and distal fibula were fixed with 1/3^rd tubular plate through the interval between tendoachillies and the posterior border of fibula (Fig. 2a) followed by a medial minimally invasive plate osteosynthesis approach using a locking compression plate for medial malleolus (Fig. 2b). For left ankle through the anterolateral approach, distal tibia was fixed with a locking compression plate and the fibula was fixed with a titanium elastic nail system. Intra-operative fluoroscopy was used to confirm optimal hardware placement and fracture reduction.

Postoperatively, the patient was managed with elevation, ice packs, and pain control. Physical therapy was initiated early to prevent joint stiffness and muscle atrophy. Ankle movements were started on post-operative day 3, and bedside sitting with knee bending was started on post-operative day 5. Weight-bearing was restricted initially, and progressive weight-bearing was allowed after 2 months, based on radiographic and clinical criteria. The patient showed satisfactory wound healing and was discharged home with instructions for partial weight-bearing and outpatient physical therapy. (Fig. 3 & 4).

The patient was seen regularly in the orthopedic clinic for follow-up radiographs and clinical assessment at 6 weeks, 3 months, 6 months, and 1 year using the foot and ankle disability index. At the 1 year follow-up, she demonstrated good functional recovery (Fig. 5a, b, and c) with resolution of pain and restoration of ankle range of motion. X-rays (Fig. 4a, b, c, and d) showed adequate healing of the fractures with intact hardware and no signs of malunion and non-union.

Ankle fractures are a very common traumatic injury. Bilateral ankle trimalleolar fractures are rare and challenging injuries. Nagasawa et al. reported that bilateral trimalleolar ankle fractures are rare and had found only one previous article regarding this topic ^[1]. McDaniel and Wilson described a total of 51 trimalleolar ankle fractures in 50 consecutive patients, including only one patient with bilateral trimalleolar ankle fractures. Sultan et al. reported that bilateral ankle fractures are rare ^[2]. Alrashedan et al. reported that for low mechanism injury ankle fractures rotational moment being an essential part results from the pivoting force on the supported leg whereas the contralateral leg is off the ground or bearing less weight. Bilateral ankle fractures are rare due to the simultaneous bilateral similar moments which is an extremely rare sequence of an injury ^[3]. The mechanism of injury, in this case, was fall from height resulting in significant force transmitted to both ankles simultaneously. Early recognition, prompt surgical intervention, and comprehensive rehabilitation are crucial for optimizing outcomes in such complex fractures. Despite the initial severity, our patient achieved satisfactory functional recovery and returned to her normal activities by 1 year post-injury. [4-11].

This case highlights the management and outcome of bilateral ankle trimalleolar fractures, which is one of the rare cases, following a traumatic fall. Multidisciplinary care involving orthopedic surgeons, nurses, physical therapists, and radiologists is essential for achieving optimal outcomes and ensuring the early return to function for patients with such injuries. Through pre-operative radiograph evaluation, proper intra-articular reduction and fixation lead to early mobility and reduce the risks of arthritis. Based on our experience with this rare case, we have provided a more insightful conclusion that discusses the specific management considerations for bilateral ankle fractures. We acknowledge that while the management aligns with standard practices, the simultaneous occurrence of bilateral ankle fractures presents unique challenges in terms of surgical and post-operative rehab to make the patient fully ambulatory and pain-free.

The occurrence of bilateral ankle fracture is rare and thorough pre-operative planning is essential for a clinically and radiologically acceptable outcome. This case report highlights the meticulous management of bilateral intra-articular ankle fractures.