Ankle Fractures: Clinical Guidelines

List of Abbreviations

EAF – external fixation apparatus

AO – Association for Osteosynthesis

ALT – alanine aminotransferase

AST – aspartate aminotransferase

Tibia – tibia

TCJ – talocrural joint

VTE – venous thromboembolism

AJ – ankle joint

DT – diaphyseal tibia

DITF – distal tibiofibular syndesmosis

ДТП - motor vehicle accident

PTP – posterior lip of the tibia

HDL — high-density lipoproteins

LDL – low-density lipoproteins

PT – physical therapy

Fib – fibula

MRI — magnetic resonance imaging

INR – international normalized ratio

LMWH – low-molecular-weight heparin from group B01AB Heparin group

NSAIDs – nonsteroidal anti-inflammatory drugs from group M01A Nonsteroidal anti-inflammatory and antirheumatic products

UFH – unfractionated heparin from group B01AB Heparin group

LMF – lateral malleolus fracture

PFib – fibular fracture

MMF – medial malleolus fracture

Russian Ministry of Health - Ministry of Health of the Russian Federation

MRI — magnetic resonance imaging

ПАП - perioperative antibiotic prophylaxis

PCD – primary surgical wound debridement

SCT – spiral computed tomography

RF – risk factors

PRM – physical and rehabilitation medicine

FS – functional status

ECG – electrocardiography

SAP – surgical antibiotic prophylaxis

LCP – locking compression plate

MIPO – minimally invasive plate osteosynthesis

ORIF – open reduction internal fixation

Terms and Definitions

Absolute stability – absence of fragment micromotion, provided there is anatomical reduction and interfragmentary bone compression after fixation with hardware.

Allograft - a fragment of another person's (donor's) bone tissue, typically cadaveric, that has undergone a preservation procedure.

External fixation apparatus (EFA) – an orthopaedic device comprising an implant (a transosseous or extracortical element protruding through the skin, reaching or embedded in the bone) and an external (non-implantable) support connecting bone fragments via transosseous elements in the treatment of fractures, pseudarthrosis, or gradual lengthening (correction of deformity) of a segment.

Autograft - a fragment of the patient's own bone harvested from a donor site for transplantation to replenish a bone tissue deficit (bone defect).

Internal fixator – an orthopaedic implant surgically implanted beneath the patient's skin to connect bone fragments in the treatment of fractures, deformities, or pseudarthrosis.

Impression – the process of articular surface fracture formation due to excessive pressure from the articulating bone exceeding the strength of cancellous bone tissue, as well as the resulting impression fracture.

Fracture consolidation - the mutual joining of fragments by living bone tissue due to the successful completion of the reparative regeneration process.

Contracture – limitation of the range of motion in a joint.

Bone fragment – a portion of bone separated as a result of injury, surgical intervention, or a destructive process.

Migration of fixation elements – loss of the optimal position of fixation elements due to bone resorption around them, occurring when permissible cyclic loads or their number are exceeded, or due to errors in the technique of inserting the element into the bone (within the scope of the topic discussed).

Load – mechanical force applied to a limb, bone, and fixation system during treatment, typically recurring with constant periodicity (cyclically).

Impaired bone healing – alterations in reparative bone regeneration leading to decreased rate, cessation, or formation of a callus insufficient to perform mechanical function.

Post-traumatic deformity - fracture consolidation with a violation of spatial, including axial and rotational, relationships between fragments.

Fixation stability – the resistance of the system to external loads, allowing it to maintain the constancy of the mutual orientation of fragments and the optimal distance between them.

Fixation – a state in which relative or complete immobilization of fragments is achieved.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Fractures and fracture-dislocations of the ankle joint region encompass fractures of the lateral malleolus (FLM), medial malleolus (FMM), posterior lip of the tibia (FPLT), fracture with damage to the anterolateral fragment of the tibial pylon (Chaput tubercle), fibular fracture at various levels accompanied by rupture of the ankle ligament complexes, rupture of the lateral ligament complex, medial ligament complex, injury to the distal tibiofibular syndesmosis in the form of ruptures of the anterior and/or posterior tibiofibular ligament complexes, as well as various combinations of these injuries. These fractures represent a disruption of the integrity of bony structures and ligamentous structures participating in the formation and stabilization of the ankle joint. When a fracture of bony structures is combined with ligamentous injuries resulting in incongruity of the articular surfaces of the tibia, fibula, and talus, a foot subluxation (if contact between articular surfaces is maintained) or complete dislocation (if contact is absent) is determined. In case of incongruity of the articular surfaces forming the ankle joint, the diagnosis of fracture-dislocation, dislocation, or subluxation of the foot is established. This group includes injuries affecting the talocrural, distal tibiofibular, and talofibular joints [1–5].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Malleolar fractures more frequently result from indirect traumatic energy. In this case, ankle joint (AJ) injury occurs via a rotational mechanism, causing the destruction of structures stabilizing the joint "mortise". All malleolar fractures can be divided into stable and unstable. Following this concept, the ankle mortise can be conditionally considered as a ring consisting of three bones and the ligaments connecting them. The stability of this ring is determined externally by the lateral malleolus or lateral ligament complex, internally by the medial malleolus or deltoid ligament complex, anteriorly by the anterior portion of the distal tibiofibular syndesmosis (DTFS), and posteriorly by the posterior portion of the DTFS [5, 6]. A single injury to the ring, such as an isolated lateral malleolus fracture, cannot lead to anteroposterior or lateral displacement of the talus and is therefore stable [5, 6]. To produce instability, two or more injuries must be present, which may be represented either by a bimalleolar fracture or a fracture of one malleolus combined with a rupture of one of the ligament groups [5, 6]. In 20–45% of cases, malleolar fractures are accompanied by DTFS injury [7]. In 7–40% of cases, they are combined with a fracture of the posterior lip of the distal tibial metaphysis [8, 9]. This combination of fractures constitutes a group of severe, unstable AJ injuries accompanied by foot subluxations or complete dislocations. To date, their treatment is associated with a high rate of unsatisfactory outcomes, primarily caused by the lack of precise anatomical reduction of fragments [10] or concomitant intra-articular chondral injuries leading to the development and progression of osteoarthritis [11].

1.2.1. Etiology and pathogenesis features in pediatric patients

Ankle fractures in children can be avulsion and physeal. The presence of a growth plate (physis) explains the differences in injuries in children compared to adults. Open growth plates decrease the likelihood of ligamentous and tibiofibular syndesmosis injuries – compared to stronger ligaments, growth zones are more vulnerable to shear and rotational loads. Injury mechanisms that might lead to ankle sprains in adults are more likely to result in physeal or avulsion fractures in children. Most frequently, ankle avulsion fractures in children occur with an inversion injury mechanism. A subgroup of ankle fractures in children, termed transitional fractures, can occur within a 1.5–2-year age "window" (in girls aged 12–15 years and boys aged 14–18 years) because gradual closure of the distal tibial growth plate occurs during this age, starting centrally and ending laterally. Triplane fractures occur in the early stages of growth plate closure, while juvenile Tillaux fractures occur when closure is nearly complete. Since the majority of the growth plate is already closed at this age, these fractures are not complicated by significant bone growth disturbances. Triplane fractures represent a complex, transitional, multiplane variant of Salter-Harris type IV fractures occurring in adolescents at a developmental stage characterized by asymmetric partial closure of the distal tibial growth plate. These fractures account for 5–10% of intra-articular ankle fractures in children. The triplane configuration consists of fracture lines running in the frontal plane through the posterior metaphysis, in the sagittal plane through the epiphysis, and in the horizontal plane through the physis.

1.3 Epidemiology of the Disease or Condition

Ankle fractures account for up to 9% of all limb bone fractures [12], with an incidence of 179 per 100,000 population per year [13]. According to Juto H. et al. (2018), females predominate in this patient group, accounting for 58.4% [13], and the majority of injuries (68.2%) are low-energy. The mean age of the victims is 45 years [14], with two age peaks. In young patients, ankle fractures occur more frequently in men, whereas in elderly patients, they are more common in women [13, 14].

The cause of the ankle injury under study is most often a low-energy trauma resulting from foot inversion and a fall from standing height (more commonly in women) or during sports activities (more commonly in men). In 1.5% of cases [13], ankle fractures are open. In some cases, injuries at the ankle level can result from high-energy trauma, such as a fall from a significant height or a motor vehicle accident. These injuries are typically more severe, involving the entire complex of ankle stabilizers and the distal tibiofibular syndesmosis (DTFS). Type C ankle fractures according to the AO/ASIF classification predominate in this group. Low-energy ankle fractures are most often types A and B according to AO/ASIF and may occur against the background of a systemic decrease in bone mineral density [3, 5]. In recent decades, there has been an increase in the absolute number of patients presenting with low-energy ankle fractures [15]. Predisposing factors for more severe ankle injuries include obesity [16, 17] and alcohol abuse [18].

1.3.1. Epidemiology features in children

Ankle fractures in children occur at an average rate of 1 per 1,000 children per year [19]. The true incidence of ankle fractures in children is likely higher, as avulsion fractures of the lateral malleolus are frequently missed and interpreted as ligament sprains. The mean age of a child sustaining an ankle injury is 10 years, and the majority of patients are boys. Such injuries most commonly result from foot inversion during sports or active games [20].

1.4 Features of Coding the Disease or Condition

S82.4 – Fracture of fibula alone

S82.40 – Closed fracture of fibula alone

S82.41 – Open fracture of fibula alone

S82.5 – Fracture of medial malleolus

S82.50 – Closed fracture of medial malleolus

S82.51 – Open fracture of medial malleolus

S82.6 – Fracture of lateral malleolus

S82.60 – Closed fracture of lateral malleolus

S82.61 – Open fracture of lateral malleolus

S82.7 – Multiple fractures of lower leg

S82.70 – Closed multiple fractures of lower leg

S82.71 – Open multiple fractures of lower leg

S93.0 – Dislocation of ankle joint

1.5 Classification of the disease or condition

Ankle fractures belong to the group of intra-articular fractures of the ankle joint. Distinctions are made between isolated fracture of the lateral malleolus, isolated fracture of the medial malleolus, bimalleolar fracture, and trimalleolar fracture (combining a fracture of both malleoli with a fracture of the posterior tibial margin) [1, 2]. Ankle fractures may be non-displaced, with preservation of articular surface congruity. These fractures are not accompanied by dislocations or subluxations of the ankle joint and are stable. Fractures with bone fragment displacement are accompanied by injury to the ligamentous structures stabilizing the ankle joint, lead to the development of ankle dislocations and subluxations, and are considered unstable injuries.

From the perspective of surgical treatment strategy, the AO/ASIF (Association for Osteosynthesis) classification is currently the most widely used. According to the universal AO fracture classification, ankle fractures correspond to code 44. Fractures are subdivided into three types based on the location of the fracture line in the lateral malleolus relative to the distal tibiofibular syndesmosis: Type A – infrasyndesmotic, Type B – syndesmotic (transsyndesmotic), and Type C – suprasyndesmotic fractures [21]. Ankle fracture subtypes also have numeric designations (1, 2, 3) determined according to the following principles:

44A – infrasyndesmotic fibular fracture;

44A1 – isolated infrasyndesmotic fibular fracture;

44A2 – infrasyndesmotic fibular fracture with medial malleolar fracture;

44A3 – infrasyndesmotic fibular fracture with dorsomedial tibial fracture;

44B – transsyndesmotic fibular fracture;

44B1 – isolated transsyndesmotic fibular fracture;

44B2 – transsyndesmotic fibular fracture with medial injury (deltoid ligament injury or medial malleolar fracture);

44B3 – transsyndesmotic fibular fracture with medial injury (deltoid ligament injury or medial malleolar fracture) and posterior tibial margin fracture (Volkmann fragment);

44C – suprasyndesmotic fibular fracture;

44C1 – suprasyndesmotic injury, simple diaphyseal fibular fracture;

44C2 – suprasyndesmotic injury, wedge or comminuted diaphyseal fibular fracture;

44C3 – suprasyndesmotic injury, proximal fibular fracture.

Comments. The AO classification is based on the Danis–Weber classification. According to literature data, the frequency of occurrence by fracture type is as follows: Type A – 38%, Type B – 52%, Type C – 10% [14].

To determine the indications for surgical fixation of the posterior tibial margin, it is advisable to use the Bartoníček et al. (2015) classification of posterior malleolar fractures, which is based on CT scan data [22, 23].

According to this classification, there are 4 types of posterior tibial margin fractures (Volkmann fragment):

Type 1 – extra-incisural fragment with an intact fibular notch (8%);

Type 2 – intra-incisural posterolateral fragment involving 1/3 to 1/4 of the fibular notch (52%);

Type 3 – intra-incisural posteromedial two-part fracture, including the posterior part of the fibular notch laterally and the posterior part of the medial malleolus medially (28%);

Type 4 – large triangular posterolateral fragment, including the posterior half of the fibular notch (9%) [22].

The classification that takes into account the mechanism of injury, foot position at the time of injury, and the direction of the deforming force is the Lauge-Hansen classification (1950) [24]. This classification divides ankle fractures into five main types. For each type, the foot position at the moment of injury and the direction of the traumatic force are specified. At the time of injury, the foot may be pronated or supinated. During foot supination, the lateral structures of the ankle joint are subjected to tension, whereas during pronation, the medial structures are subjected to tension. Consequently, at the moment the traumatic force acts (abduction, adduction, external rotation, or vertical load) with a supinated foot, the lateral structures are injured first, while with a pronated foot, the medial structures of the joint are injured first. This explains the sequential injury of ankle structures under a specific injury mechanism. The number of injured structures, in turn, determines the severity of the injury.

Supination – external rotation: 1) Rupture of the anterior tibiofibular ligament. 2) Long oblique or spiral transsyndesmotic fibular fracture with a frontal fracture plane extending from anterior-inferior to posterior-superior. The fracture may originate below or above the attachment site of the anterior tibiofibular ligament, or at its level. If the fracture originates below the attachment site of the anterior tibiofibular ligament, the latter is not injured. Suprasyndesmotic fibular injury is rare. 3) Injury to the posterior capsule, posterior tibiofibular ligament, or avulsion of the posterior tibial margin fragment. 4) Avulsion fracture of the medial malleolus with a transverse fracture plane or rupture of the deltoid ligament.

Pronation – external rotation: 1) Avulsion fracture of the medial malleolus with a transverse fracture plane or rupture of the deltoid ligament. 2) Rupture of the anterior tibiofibular ligament and interosseous ligament. 3) Short oblique-spiral suprasyndesmotic fibular fracture (6–7 cm above the joint line or more proximally), accompanied by rupture of the interosseous membrane up to the level of the fracture. 4) Fracture of the posterior margin or rupture of the posterior tibiofibular ligament.

Pronation – abduction: 1) Avulsion fracture of the medial malleolus with a transverse fracture plane or rupture of the deltoid ligament. 2) Rupture of the anterior and posterior tibiofibular ligaments. 3) Bending fracture of the fibula immediately above the ankle joint or more proximally, frequently combined with a fracture of the lateral margin of the tibial articular surface. The fibula fracture may be short oblique, transverse, or comminuted (butterfly fragment).

Supination-adduction: 1. Avulsion transverse fracture of the lateral malleolus distal to the ankle joint (subsyndesmotic) or rupture of the lateral collateral ligaments of the ankle joint. 2. Vertical fracture of the medial malleolus passing through the metaphysis, often with an compression fracture of the articular surface.

Pronation-dorsiflexion: 1. Fracture of the medial malleolus. 2. Fracture of the anterior margin of the tibial articular surface. 3. Suprasyndesmotic fracture of the fibula. 4. Transverse fracture of the posterior margin of the tibia.

The Lauge-Hansen classification serves as a guide for the pathogenetically correct performance of indirect reduction of malleolar fractures, which is used both in closed manual reduction and during surgical intervention.

For open malleolar fractures the classification by R.B. Gustilo, J.T. Anderson (1976) [25] as modified by R.B. Gustilo, R.M. Mendoza, and D.N. Williams (1984) [26] is applied:

Type I – open fracture, the wound is minimally contaminated, wound size is less than 1 cm;

Type II – open fracture, the wound is greater than 1 cm and less than 10 cm in length without significant soft tissue damage, flaps, or skin detachment;

Type IIIA – open fracture, soft tissues cover the fragments, no periosteal stripping in the presence of extensive soft tissue damage or flaps, or in high-energy trauma regardless of wound size;

Type IIIB – open fracture with an extensive soft tissue defect, periosteal stripping, and a comminuted fracture pattern, often with significant microbial contamination of the wound;

Type IIIC: open fracture complicated by major vascular injury requiring surgical reconstruction, regardless of the extent of soft tissue damage.

1.5.1. Classification features for the pediatric age group

An adaptation of the Lauge-Hansen classification for pediatric patients is the Dias-Tachdjian classification, which takes into account the presence of growth plates. Injuries in the ankle region are categorized according to the foot position at the time of injury and the direction of the traumatic force. In addition, two specific pediatric fractures are exceptions to this classification: the Tillaux fracture (Salter-Harris III) and the triplanar fracture.

The Salter-Harris classification is the simplest and most frequently used anatomical classification system for physeal fractures. In this classification, each type of injury is assigned a prognostic significance.

Type I - Epiphyseal slip - the fracture passes exclusively through the growth plate.

Type II - Metaphyseal-epiphyseal separation - the fracture passes through the growth plate and then extends into the metaphysis.

Type III - Epiphyseal fracture - the fracture passes through the growth plate and then extends into the epiphysis.

Type IV - Metaphyseal-epiphyseal fracture - the fracture line passes through the metaphysis, growth plate, and epiphysis.

Type V - Impacted fracture with growth plate injury - a fracture with "destruction and impaction" of the growth plate resulting from axial traumatic force along the bone. This type of fracture occurs extremely rarely (about 1%), and premature closure of the growth plate is quite common.

• In children, to determine the position of the fracture line relative to the growth plate, it is recommended to use the Salter-Harris classification [27, 142].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

1.6 Clinical presentation of the disease or condition

The clinical presentation of malleolar fractures is characterized by severe pain in the ankle joint, impaired joint function, smoothing of contours and edema in the lower third of the leg and the ankle joint, and tenderness upon palpation and axial load. In the presence of displacement, dislocation, or subluxation of the joint, a deformity at the ankle level is determined, the type of which (valgus or varus deformity) is caused by the position of the foot at the time of injury, as well as the direction of the deforming force. Pathological mobility of the ankle joint and a marked impairment of its stability are observed in unstable fractures.

Complaints: pain in the ankle joint area, impairment and sharp pain upon flexion and extension of the foot, pathological mobility, ankle joint deformity, swelling and edema of the lower leg, ankle joint, and foot, pain in the wound area (in open fractures), presence of subepidermal blisters («phlyctenae») with exudate, and areas of skin de-epithelialization during rapid progression of soft tissue edema.

Anamnesis: a history of trauma, with the patient describing a characteristic mechanism of injury. In most cases, this is an indirect, rotational injury in the form of foot inversion and a fall from standing height (68.2% [13]). Excessive rotation in the ankle joint with a fixed foot also leads to fractures and fracture-dislocations of the joint with rupture of ligamentous complexes during sports injuries (skating, rollerblading, or running in team sports). In addition, a possible mechanism may be a fall from a height with landing (axial load and direct impact) onto the ankle joint region, provided the foot is in a "non-physiological" position of pronation or supination, abduction, adduction, or external rotation. Such a mechanism occurs when falling from a small height (about 1 m), from stairs, or upon incorrect landing in parachute jumps. With such an injury, bone fragments are comminuted, can be accompanied by damage and partial impression of the tibial articular surface, rupture of the distal tibiofibular syndesmosis or complete rupture of the tibiofibular articulation, interosseous membrane, and wedging of the talus between the fibula and tibia. Direct impact to the ankle joint area is also possible in a traffic accident. Both low-energy and high-energy ankle injuries are accompanied by soft tissue damage and are open in 1.5% of cases [13].

Objective status: edema of the ankle region, limitation of active and passive movements due to severe pain, visually determined ankle joint deformity, tenderness upon palpation in the ankle region, crepitus of bone fragments, and pathological mobility of the ankle joint [1 – 5].

If anywhere from several hours to several days have passed since the injury, edema is observed in the lower leg, ankle joint, and foot, the severity of which correlates with the severity of the injury and the time elapsed since the trauma. With severe edema, phlyctenae with serous and/or hemorrhagic exudate may form, subsequently resulting in areas of epidermal de-epithelialization and areas of developing skin necrosis of varying depth in the form of a "dry" or infected scab.

In addition, given the soft tissue deficit, several hours after the injury, local subcutaneous hemorrhage is observed, usually localized at the site of bone and ligamentous apparatus damage.

With prolonged persistence of ankle joint deformity and high-energy fractures accompanied by pronounced edema, impairment of peripheral circulation, foot innervation, and the development of compartment syndrome are possible [5].

If a malleolar fracture is suspected, all patients must be evacuated to a medical facility to verify the diagnosis.

1.6.1. Pediatric age characteristics

Malleolar fractures in children have a prominent clinical picture, including edema, pain, and functional impairment. Such injuries most often occur during active games and sports (football). The mechanism of injury is most commonly inversion (rolling of the foot), and less frequently, rotation of the leg while the foot is fixed on a support surface.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

- anamnestic data: indication of a characteristic mechanism of lower limb injury (rolling of the foot, fall, impact to the ankle region, traffic accident, etc.)

- physical examination findings: impairment of the injured segment's function, deformity, local edema, and tenderness of the injury area (tenderness increases with axial loading), presence of pathological mobility and/or fragment crepitus

- instrumental examination data: radiographic signs of fracture based on X-ray results in 2 projections. For ankle fractures with suspected instability, additional CT is recommended as prescribed by the on-duty or attending trauma surgeon to clarify the nature of the fracture and determine the degree of fragment displacement.

• In children, to determine the indications for foot radiography in case of traumatic injury, it is recommended to use the Ottawa rules [28].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comments: The Ottawa rules (University Hospital, Ottawa, Canada) were developed to determine the appropriateness of foot radiography in traumatic injury. Initially developed for adult patients, their accuracy has subsequently been demonstrated in children over 5 years of age. Based on these criteria, performing foot and ankle X-rays is justified if the patient is unable to take four steps with full weight-bearing on the injured foot, as well as the presence of pain or tenderness upon palpation over the navicular bone, the base of the fifth metatarsal bone, and the apex or posterior surfaces of the medial and lateral malleoli along the proximal 6 cm.

2.1 Complaints and Anamnesis

In most cases, patients present with complaints described in Section 1.6 "Clinical Presentation"

• All patients with suspected malleolar fractures are recommended to undergo a thorough collection of complaints and medical history for diagnostic purposes [1 – 5].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

2.2 Physical Examination

Physical examination findings are described in Section 1.6 "Clinical Presentation"

• In all patients with suspected malleolar fractures, evaluation of the following parameters is recommended no later than 1 hour after admission to the inpatient facility for diagnostic purposes, with mandatory recording of the results in the medical chart:

- assessment of somatic status;

- visual and palpation assessment of local status [1 – 5, 134].

Leveled position 5Level of recommendation evidence C (level of data reliability - 5).

• measurement of blood pressure on peripheral arteries;

• general thermometry;

• assessment of the risk of venous thromboembolism (Appendix A3.7, G1) [29].

LOD 5Level of evidence C (reliability level of evidence - 5).

• All patients with suspected ankle fractures are recommended an assessment of the innervation and blood circulation status in the peripheral parts of the lower extremity in order to rule out neurovascular bundle injury at the fracture level [1 – 5, 134].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• All patients with suspected ankle fractures are recommended an assessment of soft tissue condition and the severity of edema in order to rule out hematomas and open fractures [1 – 5, 134].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. The presence of edema or subcutaneous hematoma in the projection of the medial malleolus and medial ligament complex in the presence of a lateral malleolus fracture and the absence of a medial malleolus fracture on radiographs indicates a suspected deltoid ligament rupture and the presence of an unstable ankle joint injury [1 – 5, 134].

• When making a decision on surgical treatment for an ankle fracture in adult patients, it is recommended to take a medical history and perform a physical examination to identify cardiovascular risk factors and diseases [30, 31].

GCR ALEL 3Grade of Recommendation A (Level of Evidence - 3).

Comment: Cardiovascular disease risk factors include: arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, and a family history of premature cardiovascular disease (<55 years for men and <65 years for women) [30]. Established cardiovascular disease is defined as: coronary artery disease, cerebrovascular disease, peripheral arterial disease, heart failure, pulmonary hypertension, valvular heart disease, or cardiomyopathies [31, 32].

• All adult patients scheduled for elective surgical treatment of an ankle fracture are recommended an assessment of the risk of perioperative cardiovascular complications, taking into account the type of planned treatment regardless of the presence of comorbidities [30, 33].

GLE ALOD 3Level of evidence A (reliability level of evidence - 3).

Comments: When surgical treatment is performed for emergency (<6 hours) and urgent (6–24 hours) indications, preoperative risk assessment is not performed.

Minor orthopedic surgeries are associated with a low risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is less than 1%). Major orthopedic surgeries are associated with an intermediate (moderate) risk of cardiovascular complications (30-day risk of myocardial infarction or cardiovascular death after surgery is 1–5%) [34].

• To assess the risk of perioperative cardiovascular complications in adult patients, it is recommended to use a special algorithm (Appendix G2) [33, 35].

GLE BLOD 3Level of evidence B (reliability level of evidence - 3).

• Elective surgical treatment for an ankle fracture is recommended without additional workup in adult patients whose risk of cardiovascular complications is determined to be low. In patients with intermediate or high perioperative risk of cardiovascular complications, an assessment of the patient's functional status is recommended [34, 36].

GCR ALEL 3Grade of Recommendation A (Level of Evidence - 3).

2.3 Laboratory Diagnostics

• All patients diagnosed with an ankle fracture who are scheduled for surgical treatment are recommended to undergo the following laboratory tests for diagnostic purposes:

- complete blood count;

- urinalysis;

- general general-practice blood biochemistry: total bilirubin, ALT, AST, urea, creatinine, total protein, glucose;

- determination of main blood groups by the ABO system and determination of the D antigen of the Rhesus system (Rh factor);

- determination of hepatitis B virus surface antigen (HbsAg) in the blood;

- determination of class G antibodies (anti-HCV IgG) to hepatitis C virus in the blood;

- determination of antibodies to Treponema pallidum in the blood;

- determination of antibodies of classes M and G (IgM, IgG) to human immunodeficiency virus HIV-1/2 and p24 antigen (Human immunodeficiency virus HIV 1/2 + Agp24) in the blood;

- coagulogram (exploratory hemostasis study) with determination of the INR [37 - 39].

LOD 5Level of evidence C (reliability level of evidence - 5).

• When making a decision on surgical treatment for an ankle fracture in adult patients, it is recommended to test the blood level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in case of intermediate or high risk of cardiovascular complications and low functional status (see Appendix G2) [30, 34, 40, 41].

LOD 2Level of evidence B (reliability level of evidence - 2).

2.4 Instrumental Diagnostics

• All patients with suspected ankle fractures are recommended to undergo radiography of the ankle joint including the entire tibial diaphysis in two projections for diagnostic purposes [1–5, 134]. To visualize the state of the distal tibiofibular syndesmosis (DTFS) and assess the congruence of the tibiotalar and talocrural joints, an additional anteroposterior radiograph of the ankle joint with internal rotation of the foot by 15-20 degrees is recommended.

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: To evaluate ankle radiographs and identify existing injuries, as well as to assess the correctness of reposition or surgical treatment results, it is recommended to use the following radiological parameters identified on radiographs [5, 7, 40]:

- the medial part of the tibiotalar articulation (TTA) in the proximal and medial joints should be equal, less than 5 mm, and no more than 2 mm greater than the lateral TTA;

- the lateral part of the TTA at a height of 10 mm from the joint line, determined as the overlapping contours of the tibia and fibula, should be less than 5 mm on the anteroposterior view and less than 1 mm on the internally rotated view;

- length of the fibula – on the internally rotated view, the articular margins of the lateral malleolus and talus should be parallel; on the anteroposterior view, the “ball sign” (a continuous semicircular line formed by the lateral process of the talus and the apex of the lateral malleolus) should be determined. The axis of the talus (the line connecting the apices of the lateral and medial malleoli) should be at an angle of 83 degrees to the tibial axis – the displacement of the lateral and medial malleoli and the posterior edge of the tibia based on reposition or osteosynthesis results should not exceed 2 mm.

In a number of cases, for accurate verification of radiographic data, it is recommended to perform radiography of the contralateral limb and compare the obtained data.

• All patients with ankle fractures are recommended to undergo stress radiography of the ankle joint in case of an isolated lateral malleolus fracture, in order to rule out an unstable nature of the ankle injury, as well as to clarify the diagnosis and address the need for surgical treatment [4, 5, 40, 41].

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2).

Comments. Stress radiography is usually performed on days 5-7 after the injury, after primary soft tissue edema has subsided. Stress radiographs are performed using manual manipulation – external rotation of the foot in the supine position and obtaining the 20-degree internal rotation projection. An alternative option is the gravity stress test – the patient lies on their side with the foot "hanging" free. Widening of the medial joint space by more than 5 mm and increasing foot subluxation in a patient with an "isolated" lateral malleolus fracture is evaluated as a positive stress test, indicating an existing injury to the medial ligament complex and the presence of an unstable ankle fracture with corresponding recommendations for surgical treatment [5].

• All patients with ankle fractures with suspected unstable fracture are recommended to undergo computed tomography of the joint to clarify the diagnosis [1 – 5].

GPP ALE 2Grade of Recommendations A (Level of Evidence 2).

Comments: MDCT provides the traumatologist with additional information on the nature of the fracture, the degree of fragment displacement, the nature of DTFS injury, and the presence of articular surface depression, thereby significantly improving the quality of preoperative planning [3, 5, 8, 9, 22]. A thorough evaluation of 3D reconstructions, coronal, sagittal, and axial CT slices is recommended. To assess DTFS congruence on axial slices, comparison with the contralateral limb is recommended.

• All adult patients with ankle fractures are recommended to undergo vascular duplex ultrasonography (arteries and veins) of the lower extremity when impaired blood supply to the distal parts of the injured limb is suspected, in order to rule out major vessel injury [5].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• All adult patients with ankle fractures are recommended to undergo MRI of the ankle joint (magnetic resonance imaging of joints (one joint)) to rule out concomitant injury to the ligamentous stabilizers of the ankle joint [5, 40, 41].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comments: After confirming the diagnosis of ankle fractures using diagnostic imaging, the issue of hospital admission is addressed. The patient must be hospitalized if surgical treatment is planned. If conservative treatment is chosen, immobilization of the lower extremity may be performed. The method of primary immobilization will be described below in the section dedicated to conservative treatment.

• Echocardiography may be considered before planned surgical treatment of an ankle fracture in adult patients with low functional status, elevated NT-proBNP levels, left ventricular systolic dysfunction, cardiomyopathies, valvular heart disease, newly detected heart murmurs, and suspected cardiovascular disease [32, 45, 46].

LoE 3Grade of Recommendation B (Level of Evidence - 3).

2.4.1. Instrumental diagnostics features in children

Avulsion fractures of the lateral malleolus with detachment (most commonly from the lateral malleolus) of the anterior talofibular and calcaneofibular ligaments present a certain diagnostic challenge in children. The clinical picture of such injuries is often similar to that of a ligament sprain. Visualization of the bone fragment is not always possible on standard radiographs, which may necessitate additional examination (ultrasound, CT).

• If an avulsion fracture of the lateral malleolus is suspected in children, it is recommended to perform CT and MRI (computed tomography of the lower extremity / magnetic resonance imaging of the lower extremity and/or joints (single joint)) to visualize the injury [49].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

• To assess the severity of ligamentous apparatus injuries in children, ultrasound diagnostics (ultrasound examination of tendons) is recommended [50].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

2.5 Other Procedures

• When providing care to patients with ankle fractures, the attending physician is recommended to take into account the following indications for consultations with related specialists in order to rule out conditions threatening the patient's life and health:

- neurosurgeon consultation: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- general surgeon consultation: in case of suspected or objectively diagnosed concomitant abdominal and/or chest trauma;

- neurologist consultation: in case of nerve injury or suspected nerve injury and concomitant traumatic brain injury;

- cardiovascular surgeon consultation: in case of concomitant vascular injury or suspected vascular injury;

- physician (internist) consultation: in case of concomitant medical conditions (according to history) [1][51].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• If acute or unstable clinical conditions are detected, it is recommended to postpone elective surgery until cardiac status improves and the patient's condition stabilizes; transfer of the patient to a regional vascular center or a specialized cardiology department is indicated [34].

GoR BLoE 5Grade of Recommendation B (Level of Evidence – 5).

2.5.1. Pediatric age characteristics

Consultations with pediatric subspecialists are also prescribed to children with distal leg injuries when there are appropriate indications.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Upon admission to the hospital, patients with ankle fractures are recommended the following minimum scope of care in the emergency department to stabilize general condition and reduce the risk of complications:

- Ensuring thermal comfort for the patient

- Adequate analgesia

- Immobilization of the injured lower extremity

- Correction of fluid and electrolyte imbalances

• All patients with ankle fractures are recommended to undergo conservative treatment to achieve bone union in the following cases:

- isolated lateral malleolus fracture without fragment displacement;

- isolated medial malleolus fracture without fragment displacement;

- stable ankle joint fracture (i.e., injury to no more than 1 ankle stabilizer), which is equivalent to the first two points;

- fracture in elderly patients with severe comorbidities and low quality of life expectations;

- presence of comorbidities that serve as a contraindication to surgery;

- voluntary patient refusal of surgery [1, 3 – 5, 134].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: Conservative treatment consists of closed reduction of fragments under adequate anesthesia, closed manual reduction of fragments, and immobilization. When performing reduction, it is necessary to take into account the fracture type according to Lauge-Hansen (1950) and perform manipulations (traction, supination or pronation, adduction or abduction) in the reverse order of the fracture mechanism [1, 2, 5]. The quality of the performed reduction must be checked by radiographs in anteroposterior and lateral projections. Criteria for adequate closed reduction are the elimination of gross fragment displacement and restoration of ankle joint congruence. In case of failed closed reduction of fragments, temporary immobilization by one of the generally accepted methods and preparation for surgical treatment are indicated.

Immobilization of the injured lower extremity is performed using various types of fixing bandages. In case of closed manual reduction, it is recommended to use a U-shaped plaster splint supplemented with a posterior plaster splint up to the knee joint level. For an isolated lateral malleolus or medial malleolus fracture without significant fragment displacement and no signs of ankle joint instability, conservative treatment [51, 52] using a circular initially-split plaster cast is indicated [1, 2]. After the edema subsides, if conservative treatment is to be continued, it is recommended to apply a circular plaster cast on days 10-14. Also, in case of a stable ankle fracture, immobilization using commercially available braces and rigid fixators is possible [5]. Follow-up control radiographs of the ankle must be performed on day 7 (5-10) after trauma to rule out secondary fragment displacement. The duration of immobilization and axial load restriction is determined by the dynamics of radiological healing signs and usually lasts up to 6-8 weeks after trauma, with repeat control radiographs of the ankle 6 weeks after trauma [1, 2, 5, 51, 52].

• All adult patients with foot dislocation or subluxation in the ankle joint are recommended to undergo additional diagnostic imaging examinations (computed tomography of the lower extremity / magnetic resonance imaging of the joints (single joint) and/or lower extremity) to clarify the diagnosis [1-3, 5].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Foot dislocation does not occur without concomitant injury to the bone structures forming the ankle joint. Therefore, upon detecting a foot dislocation or subluxation, the attending physician should conduct further diagnostic workup to clarify the nature of the injury and identify all damaged anatomical structures [1-3, 5].

• Reduction of foot dislocation or correction of subluxation to restore the congruence of articular surfaces is recommended to be performed in all adult patients under local or general anesthesia, followed by a decision on further treatment tactics (conservative or surgical) [1-3, 5].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: After reduction of foot dislocation or subluxation, to monitor the relationships in the ankle joint and the position of bone fragments, it is necessary to perform a control radiography of the injured ankle joint in two standard projections [1-3, 5].

3.1.1. Conservative treatment features in pediatric patients

• In children with non-displaced fractures, conservative treatment in the form of gypsum immobilization (application of a plaster cast for bone fractures) is recommended [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with displaced ankle fractures, closed reduction is recommended [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, if the first closed reduction attempt fails, open reduction is recommended to minimize trauma to the growth plate and articular surfaces [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with stable non-displaced fractures or following closed reduction, fixation of the foot extending to the upper third of the leg is recommended for immobilization [54].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

• In children with unstable ankle fractures, following closed reduction, it is recommended to apply a plaster cast involving the knee joint (a plaster cast extending to the upper third of the thigh with the knee flexed at an angle of 45–60°) to prevent secondary fragment displacement [55].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

• For children, plaster splints, circular plaster casts, primarily slit circular plaster casts, and foot fixators (orthopedic fixation devices – orthoses) are recommended for gypsum immobilization [56].

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2).

• In children with ankle fractures, monitoring the patient's general condition, the severity of edema, trophic and neurological disorders is recommended to prevent complications such as soft tissue compression, compartment syndrome, etc. [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, radiological control (ankle/malleolus radiography) is recommended after 5–7 days to rule out secondary fragment displacement [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, the duration of gypsum immobilization is recommended to be determined based on the fracture type and the rate of consolidation (approximately 3–6 weeks) [54].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

• In children with stable ankle fractures, it is recommended to use braces or gypsum immobilization with early weight-bearing to achieve a more rapid recovery of motor function [57].

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2).

3.2 Surgical Treatment

Indications for surgical treatment include:

• all ankle injuries classified as unstable, even if signs of instability are detected on follow-up radiographs 7–10 days after the injury;

• presence of fragment displacement accompanied by disruption of the congruence of the articular surfaces forming the ankle joint;

• unsatisfactory results of initial closed fragment reduction;

• unsatisfactory results of conservative treatment;

• open fractures of the ankle region.

When performing plate osteosynthesis of the malleoli, the following implants are used: non-absorbable sterile bone-fixation plate with screws***, non-absorbable non-sterile bone-fixation plate with screws***, non-absorbable sterile orthopedic bone screw***, non-absorbable non-sterile orthopedic bone screw***.

The choice of surgical tactics in unstable ankle fractures is determined by the individual fracture architectonics, soft tissue condition, and patient characteristics. During osteosynthesis, the priority is anatomical fragment reduction and restoration of ankle joint stability. If anatomical reduction of comminuted lateral malleolus fractures is impossible, it is necessary to restore its length, axis, and correct rotational displacements. In all cases, one should strive for complete restoration of the anatomy of the articular surfaces forming the ankle joint. When using multiple surgical approaches, it is necessary to consider the preservation of soft tissue blood supply and, to prevent complications associated with tissue ischemia between approaches, to maintain a soft tissue bridge of at least 7 cm between the surgical approaches.

3.2.1. Osteosynthesis of the lateral malleolus

• In adult patients with ankle fractures to create conditions for fracture consolidation, it is recommended to perform osteosynthesis of the lateral malleolus via a lateral surgical approach in cases of a combined fracture of the lateral and medial malleoli or a rupture of the deltoid ligament ("bimalleolar fracture") [1, 3-5]. The method of osteosynthesis is determined by the type and location of the fracture according to the AO classification:

- Type A — plate osteosynthesis for an apex-type fracture, or osteosynthesis using two Kirschner wires and a tension band wire (cerclage wire) or a compression screw (lag screw);

- Type B — plate osteosynthesis using anatomical reduction technique and interfragmentary compression with a lag screw for a simple (oblique or spiral) fracture, or plate bridging for a comminuted fracture or poor bone quality (osteoporosis);

- Type C — plate osteosynthesis for a fracture located in the distal third of the fibula.

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In adult patients with ankle fractures, to create conditions for fracture consolidation, osteosynthesis of the lateral malleolus via an anterolateral surgical approach is recommended when revision of the anterior portion of the distal tibiofibular syndesmosis is required, as well as in combination with a fracture of the tibial Chaput tubercle [144].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In adult patients with ankle fractures to create conditions for fracture consolidation, osteosynthesis of the lateral malleolus via a posterolateral approach is recommended in the case of a concomitant fracture of the posterior tibial margin ("posterior malleolus, Volkmann's fragment") and the presence of indications for its fixation [3, 6, 22, 23, 53, 67].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: When performing plate osteosynthesis, plates of various shapes and configurations can be used depending on the fracture type, location, and the surgeon's preference (one-third tubular plate, reconstruction plate, straight small plate, anatomical pre-contoured plate — pre-contoured lateral malleolus plate).

Minimally invasive plate osteosynthesis can be used for comminuted fractures of the lateral malleolus under intraoperative fluoroscopic control.

Intramedullary osteosynthesis of the lateral malleolus can be used in comminuted fracture patterns and according to the surgeon's individual preferences [5].

The criterion for adequate reduction of lateral malleolus fragments is the complete restoration of its anatomy in a simple fracture, and the restoration of length, axis, and correction of rotational displacement in a comminuted fracture.

3.2.2. Osteosynthesis of the medial malleolus and repair of the deltoid ligament

• In adult patients with ankle fractures to create conditions for fracture consolidation, osteosynthesis of রহমানের the medial malleolus via a medial approach is recommended in the presence of its fracture with fragment displacement [3, 22, 68, 70].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. During revision of the medial malleolus fracture area, it is indicated to remove soft tissue interposition (fragments of periosteum, joint capsule, ligaments) from the fracture line. Anatomical "tooth-in-tooth" reduction and fixation using lag screw technique and interfragmentary compression are recommended. To avoid secondary rotational displacement, the insertion of two screws or one screw and one Kirschner wire is indicated. In comminuted fractures of the medial malleolus, fixation with two Kirschner wires and a tension band wire (cerclage wire) is possible. In vertical Type A fractures of the medial malleolus, plate osteosynthesis using a buttress plate and lag screws may be used.

• In adult patients with ankle fractures to create conditions for fracture consolidation, osteosynthesis of the medial malleolus via a posteromedial approach is recommended with simultaneous osteosynthesis of a Type 3 posterior tibial margin fracture according to J. Bartoníček et al. [3, 22, 68, 70].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments: Osteosynthesis of the posterior tibial margin fragment in identified Type 3 according to J. Bartoníček et al. is recommended to be performed using the anatomical reduction technique, guided by the contact line of bone fragments and intraoperative fluoroscopy data, achieving interfragmentary compression and stable fixation with lag screws inserted subchondrally, parallel to the joint surface and perpendicular to the fracture plane, or with a small fragment buttress plate (one-third tubular plate, reconstruction plate, T-shaped mini-plate).

• In adult patients with ankle fractures, to create conditions for fracture consolidation and increase the stability of osteosynthesis, revision and repair of the deltoid ligament are recommended if damage to its deep portion is suspected and intraoperative instability of the ankle joint persists following lateral malleolus osteosynthesis while the integrity of the medial malleolus is preserved [5, 43, 71].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. If the intraoperative stress test is negative following lateral malleolus osteosynthesis, there is no subluxation on intraoperative radiographs, and ankle stability is preserved, deltoid ligament repair is not indicated [5, 43, 71]. In such cases, ankle immobilization (using a plaster cast or specialized brace) extending to the upper third of the lower leg is recommended for 6 weeks postoperatively.

3.2.3. Osteosynthesis of the posterior malleolus of the tibia

• In adult patients with malleolar fractures, osteosynthesis of the posterior malleolus (Volkmann's fragment) is recommended in unstable malleolar fractures to create conditions for fracture consolidation [3 – 5, 7, 22, 68].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. The choice of surgical tactics regarding the posterior malleolar fragment is determined during preoperative planning, depending on the fracture type of the posterior malleolus, the size of the posterior malleolar fragment, and the degree of involvement of the tibial articular surface and the distal tibiofibular syndesmosis.

For Bartoníček type 1 fractures, operative fixation of the posterior malleolar fragment is not indicated due to its small size. However, in such cases, it is necessary to stabilize the distal tibiofibular syndesmosis, aiming to fully restore the anatomy and stability of the ankle joint.

For type 2 fractures, indications for osteosynthesis depend on the size of the posterior malleolar fragment, the presence or absence of bone impaction, and the type of fibular fracture. It is established that when a posterior malleolar fracture is combined with a high fibular fracture, reduction and fixation of even a relatively small posterior malleolar fragment significantly contributes to the anatomical reduction of the fibular fragments and their correct positioning within the fibular notch.

For type 3 fractures, surgical treatment is indicated, as reduction and fixation of displaced posterior malleolar fragments restore the congruence of the articular surfaces and ankle stability. Furthermore, if a posteromedial fragment of the medial malleolus is present, its fixation in the correct position is essential, as displacement of this fragment can cause impingement of the tibialis posterior tendon.

For type 4 fractures, open reduction and internal fixation are indicated in all cases due to the presence of a sufficiently large fragment of the tibial articular surface and the necessity of restoring articular congruence and ankle stability [22].

Thus, the presence of a posterior malleolus fracture is an indication for open reduction and fixation in the majority of cases. For Bartoníček types 2 and 4, it is recommended to use a posterolateral approach, with the patient in the supine or lateral position, simultaneously fixing the posterior malleolus and the lateral malleolus. For Bartoníček type 3, it is recommended to use a posteromedial approach, with the patient in the supine position, along with fixation of the medial malleolus fragment.

Osteosynthesis of the posterior malleolar fragment across all Bartoníček types is recommended to be performed using anatomical reduction techniques, guided by the bone fragment contact line and intraoperative radiography data, interfragmentary compression, and stable fixation using lag screws inserted subchondral, parallel to the articular surface and perpendicular to the fracture plane, or via a small fragment buttress plate (one-third tubular plate, reconstruction plate, T-shaped mini-plate) [6, 72, 73, 74].

In most cases, screws for posterior malleolus fragment fixation are inserted from back to front. The screws should ideally be inserted perpendicular to the fracture plane of the posterior malleolus. When a large posterior malleolus fragment is present, closed reduction, temporary fixation with a bone clamp, and osteosynthesis using lag screws (partially threaded 4.0 mm cancellous screws, 3.5 mm cortical screws) inserted from front to back under intraoperative fluoroscopic control can be utilized [6].

3.2.4. Fixation of the distal tibiofibular syndesmosis

• In adult patients with malleolar fractures, intraoperative assessment of the distal tibiofibular syndesmosis (DTFS) using the hook test, as well as intraoperative stress radiographs, is recommended to rule out DTFS rupture and to detect ankle instability and subluxation with widening of the medial joint space [3, 7, 42, 43].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. Assessment of the integrity and stability of the DTFS is recommended after the osteosynthesis of all other components requiring fixation (lateral malleolus, medial malleolus, and posterior malleolus) [3, 7, 42, 43]. In the event of a positive hook test or radiographic stress test, fixation of the DTFS with a positioning screw placed 1.5–2.5 cm proximal to the ankle joint line is recommended. To restore the congruence of the tibiofibular articulation and prevent anterior or posterior displacement of the fibula, the screw must be inserted parallel to the articular surface, passing obliquely through the cross-sectional centers of the fibula and tibia from lateral to medial and posterior to anterior at a 30-degree angle to the frontal plane. Radiographic control is recommended to verify DTFS restoration and correct positioning of the positioning screw. A standard 3.5 mm cortical screw, 35–40 mm in length, may be used as a positioning screw. Monocortical or bicortical fixation of the positioning screw in the tibia is acceptable. Additionally, depending on the surgeon's preference and the clinical situation, options for DTFS fixation include 4.5 mm cortical screws, two or more positioning screws, bioresorbable implants (biodegradable osteosynthesis implants), and ligament fixation systems such as Endobutton [4, 5, 7, 42, 43]. Removal of the positioning screw is recommended 8–10 weeks postoperatively, prior to initiating full weight-bearing on the injured limb. One or two positioning screws may be used.

• In patients with malleolar fractures, following the fixation of all fracture components, intraoperative radiography in three standard projections is recommended to verify the restoration of articular surface congruence, fragment and implant positioning, and ankle stability [3, 5, 7, 42, 43].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

3.2.5 Application of an external fixation device in the surgical treatment of malleolar fractures

• In adult patients with malleolar fractures, for temporary or definitive fragment fixation, external fixation devices are recommended for unstable fractures and fracture-dislocations of the ankle according to the following indications:

- open fractures with significant soft tissue injury and a high risk of infectious complications from plate or intramedullary osteosynthesis;

- unstable ankle fracture as part of polytrauma, considering staged fracture management protocols;

- extensive skin and soft tissue defects that cannot be resolved in the early post-traumatic period;

- surgical site infection;

- extensive bone defects requiring reconstruction via limb lengthening techniques;

- unsatisfactory closed manual reduction with persistent significant fragment displacement;

- risk of skin necrosis from pressure exerted by displaced fragments from within [3, 75].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

Comments. External fixation as a definitive osteosynthesis method for malleolar fractures is rarely used due to specific complications and limitations (pin-site infections, rehabilitation difficulties, patient inconvenience). As a rule, external fixation is used as a provisional osteosynthesis method in cases of open fractures and polytrauma. Subsequently, once wounds have healed and the patient's general condition has stabilized, conversion to internal fixation is performed [3, 75].

3.2.6. Surgical treatment features in pediatric patients

• In children with intra-articular fractures following a failed closed reduction attempt, anatomical reduction is recommended to prevent joint degeneration and secondary deformities associated with growth plate injury [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with unsatisfactory residual displacement after closed reduction (angular deformity greater than 15 degrees in children over 10 years of age, growth plate displacement greater than 3 mm, or articular surface step-off greater than 2 mm), surgical treatment—open reduction and stabilization—is recommended to prevent joint degeneration and secondary deformities associated with growth plate injuries [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• Plate osteosynthesis in the treatment of pediatric malleolar fractures is recommended after the cessation of bone growth to prevent secondary deformities associated with growth plate fixation [58].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• Fixation of malleolar fractures in children with open growth plates is recommended using Kirschner wires, screws, or the Weber technique to achieve stable osteosynthesis and prevent secondary deformities related to growth plate dysfunction [59].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• During internal fixation of ankle fractures in children, it is recommended to place compression screws parallel to the growth plate (without crossing it) — from epiphysis to epiphysis, from metaphysis to metaphysis to prevent secondary deformations associated with growth plate dysfunction [60].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• Transphyseal fixation elements must be removed in a timely manner to prevent secondary deformations associated with growth plate dysfunction [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, when assessing the risks of premature growth plate closure, it is recommended to take into account the magnitude of residual displacement [61].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

• In children with fractures of the tibia (Salter-Harris I, II) and fibula in the lower-middle third with insufficient stability after closed reduction, it is recommended to use Kirschner wires for adequate stabilization [62].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

• In children with a Tillaux avulsion fracture (Salter-Harris III), osteosynthesis with a compression screw without crossing the tibial growth plate (from epiphysis to epiphysis) is recommended to prevent premature growth plate closure. When closing the remaining parts of the distal tibial growth plate, transphyseal or epiphyseal placement of a compression screw is recommended for adequate reduction and interfragmentary compression [63].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

• In children, when choosing internal fixation for a medial malleolus fracture, it is recommended to avoid compression and trauma to the growth plate. For the osteosynthesis of the medial malleolus in children with open growth plates, it is recommended to use Kirschner wires, Weber tension band wiring, or compression screws without perforating the growth plate (screw from epiphysis to epiphysis, from metaphysis to metaphysis) to prevent premature growth plate closure [60].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with Salter-Harris III–IV medial malleolus fractures with a displacement of more than 1 mm, anatomic reduction with precise matching of the articular surface and growth plate is recommended to prevent premature growth plate closure [53].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, indications for the repair of the distal tibiofibular syndesmosis (suture, positioning screw, dynamic tightrope) are recommended to be determined after the osteosynthesis of bony injuries, similarly to adult patients, in order to minimize the invasiveness of the surgical intervention, since in a number of cases the stability of the tibiofibular syndesmosis is restored after the osteosynthesis of fractures [64].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• In children with ankle fractures, the use of external fixation devices is recommended in cases of extensive soft tissue damage and the impossibility of performing single-stage reduction and internal fixation [65].

GCR CLOE 4Grade of Recommendation C (Level of Evidence - 4).

3.3 Other Treatment

3.3.1. Postoperative analgesia

• For adequate analgesia in patients with ankle fractures it is recommended to use multimodal analgesia, which may include NSAIDs from group M01A (Anti-inflammatory and antirheumatic products, non-steroids), paracetamol**, gabapentinoids, and immediate-release opioids, taking into account age restrictions in the instructions for medical use; if its administration is impossible, monomodal analgesia should be used [76–78].

GPP ALE 2Grade of Recommendations A (Level of Evidence 2).

Comments: It is necessary to ensure adequate analgesia for the patient with a fracture prior to any manipulations and throughout the entire period of fracture treatment, the duration of which varies significantly depending on the chosen management strategy. When performing analgesia in a hospital setting, it is necessary to take into account prescriptions made at the emergency medical care stage. In the acute period of trauma, for the purpose of analgesia, it is necessary to ensure proper immobilization of fragments using a vacuum splint, a vacuum mattress, or an external fixation device.

Among pharmacological strategies, the current consensus is the use of multimodal analgesia (MMA), which represents the use of several analgesic drugs (opioid and non-opioid) with different mechanisms of action and non-pharmacological interventions aimed at targeting peripheral and/or central parts of the nervous system [79]. This combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescriptions and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control using different classes of medications. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids, regional anesthesia (single injection or placement of peripheral nerve catheters), local injections, and opioids [77].

In modern scientific literature, authors emphasize the use of the lowest effective doses of opioids for the shortest possible period of time, avoiding extended-release opioids. As an adjuvant during MMA, a single administration of #dexamethasone** in the perioperative period can be used, which provides a significant reduction in pain syndrome [76].

It must be remembered that the duration of parenteral administration of most NSAIDs (ketorolac**, ketoprofen**, diclofenac**) is limited to two days, which requires timely switching of the patient to oral administration, changing the drug, or coordinating further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.

When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.

Recommended analgesic medications are listed in Appendices A3.1–A3.3.

• In children with ankle fractures, the use of paracetamol** and ibuprofen** is recommended for analgesia [69].

GPP BLE 2Grade of Recommendations B (Level of Evidence 2).

• In cases of severe pain syndrome and ineffectiveness of paracetamol** and ibuprofen** in children, the use of other non-steroidal and narcotic analgesics is recommended if appropriate indications are present and contraindications are absent [69].

GPP BLE 2Grade of Recommendations B (Level of Evidence 2).

3.3.2. Surgical antibiotic prophylaxis

• During the surgical treatment of patients with ankle fractures, it is recommended to perform surgical antibiotic prophylaxis (SAP) of surgical site infection with a single preoperative administration of an antibacterial drug in order to reduce the risk of infectious complications [80–81].

GCR ALOE 1Grade of Recommendation A (Level of Evidence - 1).

Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [80, 82], the goal of SAP is to achieve bactericidal concentrations of the antibacterial drug in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The necessity of SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not associated with the placement of orthopedic implants and metal structures. SAP should be performed: for clean-contaminated and contaminated surgical wounds; for "clean" surgical wounds where orthopedic implants and metal structures are placed. In infected ("dirty") wounds, SAP is not indicated; antibiotic therapy is performed instead.

• In patients with ankle fractures, it is recommended to use first- and second-generation cephalosporins (cefazolin**, cefuroxime**) as the main drugs for surgical antibiotic prophylaxis during surgical interventions in traumatology and orthopedics, and glycopeptide antibiotics (vancomycin**), lincosamides (#clindamycin**) as alternatives in case of beta-lactam antibiotic intolerance [80].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

Comments. For patients with an unburdened allergic history and without significant risk factors for methicillin-resistant Staphylococcus carriage, first- and second-generation cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes prior to skin incision. In case of beta-lactam intolerance, a combination of vancomycin** with one of the fluoroquinolones (ciprofloxacin**, #levofloxacin**) should be prescribed, administered over at least 60 minutes starting the IV infusion 2 hours before the incision, or #clindamycin**. In the presence of significant risk factors for methicillin-resistant Staphylococcus carriage (MRS), the SAP regimen must include an antibiotic with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of the antibiotic is sufficient for effective prophylaxis. For prolonged procedures or massive blood loss, an additional intraoperative dose of the antibiotic should be administered (the approximate timing of intraoperative administration is two half-lives after the preoperative dose). Administration of the antibiotic after wound closure in the operating room is inappropriate even in the presence of placed drains.

Single doses of the main antibacterial drugs for SAP in surgical interventions in traumatology and orthopedics in adults: cefazolin** 2 g (for patients weighing ≥120 kg — 3 g), cefuroxime** 1.5 g, #clindamycin** 900 mg, vancomycin** 15 mg/kg as a slow IV infusion, ciprofloxacin** 400 mg, #levofloxacin** 500 mg. [80].

Single doses for children should be calculated based on actual body weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg; the use of fluoroquinolones during the period of musculoskeletal system development is contraindicated due to the risk of arthropathy [80, 140–141].

Comments: In case of allergic reactions, the choice of a broad-spectrum antibiotic is made individually.

• Administration of the antibacterial drug is recommended no later than 30 minutes before the start of the surgical intervention [133].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

• The choice of drug for antibiotic therapy in children is recommended to be made depending on the child's age, severity of condition, and microbial susceptibility [133].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

Comments. In open fractures, prophylactic administration of antibiotics is effective for preventing early infection, and the drug should be administered as soon as possible after trauma. Cefazolin** is the antibiotic of choice, however, in patients with open high-energy fractures with displacement and segmental bone loss, major vascular injury, and heavily contaminated wounds, it is advisable to broaden the spectrum of prescribed antibiotics to cover gram-negative pathogens. In such cases, adding #gentamicin** (at a dose of 6 mg/kg once daily) to cefazolin** may be considered for adults [84, 85]. An alternative to this combination can be #ampicillin+sulbactam** (at a dose of 3.0 g every 8 hours for 3 days) [86], the latter being especially relevant in case of the risk of clostridial infection. According to the majority of researchers, in Gustilo and Anderson type III open fractures, antibiotics should not be continued for more than 72 hours after soft tissue wound closure [87].

• During surgical treatment of patients with ankle fractures, it is recommended to perform antibiotic prophylaxis of surgical site infection for no more than 24 hours [88].

GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).

Comments. In accordance with the regulatory documentation in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [88], in order to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of the skin incision, antibiotics for the prevention of surgical site infection should be administered intravenously within 30 to 60 minutes before the skin incision, or within 2 hours before the incision when using vancomycin**. The maximum duration of prophylactic antibiotic administration should not exceed 24 hours after the end of the surgery. In most cases, a single dose of antibiotic is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the half-life of the administered antibiotic elapses from the moment of preoperative administration, creating a risk of the antibiotic concentration dropping below the bactericidal level and increasing the risk of surgical site infections (SSI).

3.3.3. Prevention of venous thromboembolic events

Comments: To assess the patient's risk of developing VTE before surgery, it is advisable to use the Caprini VTE risk scoring scales (Appendix G1).

• In all patients with ankle fractures and subsequent osteosynthesis in the absence of active bleeding, VTE prophylaxis is recommended until the patient's normal or expected mobility is restored [89, 90].

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2).

Comments: Patients with ankle fractures are classified into the moderate VTE risk group due to the nature of the fracture itself, regardless of the treatment method; therefore, along with mechanical VTE prophylaxis, this category of patients is usually indicated for pharmacological prophylaxis. Non-pharmacological methods of VTE prophylaxis include:

- Elastic and/or intermittent sequential pneumatic compression of the lower extremities.

- Early mobilization and activation of the patient.

- Therapeutic exercises.

Pharmacological VTE prophylaxis in the preoperative period is carried out with unfractionated heparin (UFH) or, preferably, low-molecular-weight heparins (LMWH) [Appendix A3.5]. The use of vitamin K antagonists monitored by INR (Determination of the International Normalized Ratio) [93] is also possible.

• In patients chronically receiving antithrombotic drugs who present with an ankle fracture, VTE prophylaxis and anesthesia are recommended based on relevant clinical guidelines for the purpose of complication prevention [93, 94].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

• In patients with ankle fractures undergoing conservative treatment and limb immobilization, VTE prophylaxis is recommended to be initiated immediately after ruling out bleeding [93].

GCR BLOE 3Grade of Recommendation B (Level of Evidence 3).

Comments: Recommended medications and thromboprophylaxis regimens are given in Appendix A3.5. Issues of VTE prophylaxis in orthopedic and trauma patients are discussed in detail in the 2022 methodological recommendations [93] and the 2023 Russian expert recommendations [95].

Recommended time intervals between the prophylactic use of anticoagulants and neuraxial interventions are given in Appendix A3.4.

Features of thromboprophylaxis in pediatric patients

• In hospitalized patients older than 6 months, it is recommended to assess bleeding and VTE risks within 24 hours of hospitalization [121] and periodically during their stay in the hospital [122–124].

GCR BLEL 3Grade of Recommendation B (Level of Evidence - 3).

Comment. Validated VTE risk assessment scales have not been developed for pediatric patients, nor have bleeding risk scales during anticoagulant therapy; therefore, when deciding to prescribe VTE prophylaxis, individual bleeding risk factors (Appendix A3.6), VTE risk factors (Appendix A3.7), and the risk-benefit ratio should be taken into account [125, 127].

For VTE prophylaxis in children, mechanical and pharmacological methods are used.

• In pediatric patients at high risk for VTE, it is recommended to consider prescribing prophylactic doses of UFH or LMWH from the B01AB group [123, 129, 130, 143].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5).

Comment. For pediatric patients, the use of LMWH is preferred [129, 130], but currently in Russia the use of all LMWHs is contraindicated in children, so their prescription is only possible by the decision of a medical commission ("off-label" use). Some foreign guidelines indicate the use of direct oral anticoagulants (#rivaroxaban**) for VTE prophylaxis in children [127], however, there is currently insufficient clinical evidence of their efficacy and safety in this patient category [126, 128].

To make a decision on pharmacological VTE prophylaxis, a consultation with a pediatrician or hematologist experienced in treating thrombosis in children is recommended. When prescribing anticoagulants to children, it is advisable to monitor general blood count parameters within 48 hours after starting treatment with enoxaparin or heparin [121]. According to indications, anti-Xa levels should be determined 4–6 hours after administration of #enoxaparin sodium** (target anti-Xa level 0.1–0.3 IU/mL). Routine monitoring of anti-Xa levels is not recommended [131]. Re-checking anti-Xa levels may be considered if active bleeding develops or if there are signs of renal dysfunction during #enoxaparin sodium** therapy [132]. The glomerular filtration rate in children receiving anticoagulants is calculated using the revised Schwartz formula (http://nephron.com/peds_nic.cgi)

3.3.4. Blood-conserving technologies

Comments. Tranexamic acid** effectively reduces blood loss and leads to a smaller decrease in postoperative hemoglobin levels in patients undergoing surgery for tibial shaft fractures. Randomized clinical trials demonstrate the efficacy of local subfascial administration of #tranexamic acid** (1.0 g in 10 mL) into the postoperative wound, comparable to the intravenous administration of an equivalent dose of the drug [98].

Comments. Systematic reviews and meta-analyses demonstrate that perioperative use of intravenous iron preparations, specifically ferric carboxymaltose**, in trauma and orthopedic patients, particularly in the postoperative period, is an effective alternative to blood transfusion, as it reduces the proportion of patients receiving blood transfusion, decreases the volume of red blood cell mass transfused, and leads to a lower incidence of infectious complications, though it does not affect mortality rates [99, 100].

Evidence for the efficacy of intravenous iron preparations for the correction of iron-deficiency anemia in the preoperative period during elective orthopedic procedures has been obtained in pediatric populations [135, 136]. Data on the use of these drugs in children in the postoperative period following trauma surgery are lacking.

3.3.5. Tetanus prophylaxis

Comments: In accordance with clauses 4156-4157 of the Sanitary Rules and Norms on the Prevention of Infectious Diseases (SanPiN 3.3686-21), emergency tetanus prophylaxis is performed for any injuries involving damage to the integrity of the skin and mucous membranes. Emergency tetanus prophylaxis is carried out up to the 20th calendar day from the moment of injury [101]. The prescription of drugs for emergency tetanus immunoprophylaxis is carried out differentially, depending on the presence of documentary confirmation of preventive vaccination or data from immunological control of antitetanus immunity levels, as well as taking into account the nature of the injuries.

Emergency tetanus immunoprophylaxis is carried out in the form of:

- passive immunization or seroprophylaxis with human antitetanus immunoglobulin** (TIG), and in its absence - tetanus antitoxin** (TAT);

- active-passive prophylaxis, consisting of the simultaneous administration into different body sites of human antitetanus immunoglobulin** (or TAT in its absence) and tetanus toxoid** (TT);

- emergency revaccination with tetanus toxoid** (or diphtheria-tetanus toxoid** with a reduced antigen content - Td-M) to stimulate immunity in previously vaccinated individuals. [101, 102].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• Postoperative mobilization of adult patients and restoration of range of motion in the ankle joint should be initiated as early as possible. Patient activation is recommended to begin within 24 hours after surgery [3, 103].

BMR BLEL 3Level of recommendation validity B (level of evidence – 3).

Comments: in patients with ankle fractures after osteosynthesis of the lateral, medial malleoli, and the posterior malleolus of the tibia, full active movements in the ankle joint are permitted. The issue of weight-bearing on the lower extremity is decided based on the dynamics of fracture healing [1-3, 5].

In the presence of a deltoid ligament injury, immobilization may be maintained for up to 6 weeks. Active movements in the ankle joint begin after the immobilization period has elapsed.

The tasks of the early postoperative period are the prevention of general postoperative complications from the cardiovascular system, respiratory organs, gastrointestinal tract, and the prevention of trophic disorders. Prevention of local complications includes reducing soft tissue edema and creating optimal anatomical and physiological conditions for the healing of tissues traumatized during surgery.

Starting from the first day after surgery, the patient is prescribed breathing exercises, active exercises for the joints of the unaffected limb, isometric exercises for the muscles of the operated limb, and passive joint movements of the operated limb under the supervision of a physical therapy instructor in the inpatient trauma department.

At the outpatient stage, a comprehensive active rehabilitation program for the operated limb is recommended, as prescribed by the physical therapy physician.

• In children, it is recommended to take into account the specific rates of bone fracture consolidation when determining the duration of immobilization, which can range from 3 weeks to 3 months depending on the degree of consolidation on radiographs, as well as clinical evaluation data [53].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Physical treatment methods.

Aim to reduce pain and edema, relieve inflammation, and improve tissue nutrition and metabolism in the surgical area. The use of physiotherapeutic procedures is indicated in the absence of contraindications, as prescribed by a physical therapy physician.

Comments: After fragment reduction in fractures of the lateral, medial malleolus and/or the posterior lip of the tibia, a plaster cast or rigid brace is applied to immobilize the ankle joint for up to 10 weeks. The duration of this period is determined by the attending physician based on the dynamics of fracture consolidation [107, 109].

A physical and rehabilitation medicine (PRM) / physical therapy physician draws up a rehabilitation program prescribing physical therapy modalities: dynamic exercises for the toes, knee, and hip joints, isometric tension exercises for the lower leg and foot muscles, and ideomotor movements in the ankle joint [110]. Patients are trained in walking with assistive devices (walkers, rolling walkers) [104, 105].

In conservative treatment with ankle immobilization, active rehabilitation begins after immobilization is discontinued. [1, 2, 5, 103].

Comments. The rehabilitation program is drawn up by a PRM/physical therapy physician with the prescription of physical therapy modalities: therapeutic gymnastics (free, assisted, and resistive exercises for the ankle joint), hydrotherapy exercise in a pool, postural correction, passive mechanotherapy for the ankle joint, and basic mechanotherapy. After two weeks, following a repeat consultation with the PRM/physical therapy physician, training on exercise equipment, exercises to strengthen the arch of the foot, balance therapy, and biofeedback (BFB) training for musculoskeletal injuries are prescribed [110, 113, 114].

Hardware and/or manual massage combined with underwater whirlpool massage is prescribed. To reduce pain and edema in the foot and ankle area, physical therapy is prescribed: local cryotherapy, transcutaneous electrical nerve stimulation (TENS), ultrasound therapy (ultrasound treatment for joint diseases), and magnetic field therapy. [105, 106, 114].

Unified rehabilitation protocols are not presented in the literature, and there is no evidence of the superiority of one rehabilitation protocol over another, which requires further study. However, the efficacy of rehabilitation has been demonstrated [105, 108, 109, 114, 115].

The question of axial load-bearing on the leg is decided individually depending on the degree of fracture consolidation [106, 111].

All patients are recommended to wear orthopedic footwear.

Comments. Postoperative patient activation and restoration of range of motion in the ankle joint should be initiated as early as possible, within 24 hours after surgery [104, 110, 113].

The rehabilitation program is drawn up by a PRM/physical therapy physician and includes: therapeutic gymnastics (free and assisted exercises for the ankle joint), postural correction, passive mechanotherapy for the ankle joint, basic mechanotherapy, local cryotherapy, and transcutaneous electrical nerve stimulation (TENS) [105, 112, 114, 115].

Subsequently, 2–4 weeks after the follow-up consultation with a physical and rehabilitation medicine (PRM) physician / exercise therapy physician, resistance exercises, stretching for the ankle joint motor muscles, foot arch strengthening exercises, gym equipment training, and biofeedback training for musculoskeletal injuries are prescribed (balance and proprioception) [104, 105, 107]. Apparatus and/or manual massage is prescribed [105, 1072, 4].

There is no unified rehabilitation protocol presented in the evidence-based literature. A consensus across all publications is the early initiation of joint movement with partial axial loading on the limb [114, 115]. There is no evidence supporting the efficacy of manual joint mobilization. Isolated studies have shown a positive effect from electrotherapy [109, 114].

The question of allowing axial loading on the lower limb in patients with malleolar fractures following osteosynthesis of the lateral and medial malleoli and the posterior malleolus of the tibia is decided based on the fracture healing dynamics [106, 111]. Limited evidence suggests that early axial loading does not cause complications and shortens final recovery time [106, 111]. Further clinical trials are needed to support these findings.

5. Prevention and Dispensary Observation

Prevention of malleolar fractures consists in citizens complying with social safety rules during household chores, staying in traffic zones, walking on poor-quality surfaces, and during icy conditions.

A significant share of responsibility in fracture prevention also belongs to state structures, which are obliged to ensure safety to prevent road traffic injuries, as well as ensure compliance with safety regulations in industries with increased risk of trauma.

Upon discharge from the hospital, the patient must be referred to a trauma center or outpatient trauma department with an indication of the treatment performed and detailed recommendations for continuing treatment and rehabilitation. This will ensure continuity between the inpatient and outpatient stages of treatment.

In patients with malleolar fractures, recommended follow-up examinations by an orthopedic trauma surgeon include radiography of the ankle joint / malleolus radiography and assessment of functional recovery dynamics:

• at 6 weeks from the time of surgery (assessment of fracture consolidation degree and the possibility of full weight-bearing on the limb),

• 12 weeks after surgery (assessment of fracture consolidation degree and the possibility of weight-bearing on the limb),

• 24 weeks after surgery (assessment of consolidation degree, assessment of functional recovery dynamics),

• 1 year after surgery (assessment of the functional outcome of treatment and deciding on the necessity and timing of implant removal) [134, 144].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• In children with fractures involving growth plate injuries, it is recommended to conduct follow-up monitoring by an orthopedic trauma surgeon and pediatric surgeon, performing control radiography of the ankle joint / malleolus radiography 6–12 months after the fracture (and further as needed) for the timely diagnosis of premature growth plate closure [61, 134].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

6. Organization of Medical Care

Clinical application of recommendations: Traumatology and Orthopedics, Anesthesiology and Intensive Care, Medical Rehabilitation, Health Organization and Public Health.

The aim of the clinical guidelines: The clinical guidelines have been developed to improve the quality of medical care, standardize diagnostic algorithms, and treatment of patients with malleolar fractures.

Indications for planned hospitalization:

• presence of an unstable malleolar fracture in the patient, detected during follow-up examinations by an outpatient trauma surgeon

• unsatisfactory result of conservative treatment – secondary fragment displacement, absence of signs of fracture consolidation after conservative treatment; secondary displacement, or implant migration after osteosynthesis surgery [1-3, 5].

Indications for emergency hospitalization:

Patients with suspected or confirmed malleolar fracture are subject to referral to a hospital to resolve the issue of emergency hospitalization necessity. Indications for emergency hospitalization are:

• malleolar fracture with significant fragment displacement, dislocation, and subluxation of the ankle joint;

• unstable ankle joint fracture (in case of suspected or verified injury to two or more bone or ligamentous stabilizers of the ankle joint);

• open fracture and fracture-dislocation in the ankle joint;

• gunshot fracture of the ankle joint region;

• malleolar fracture accompanied by damage to major vessels and nerves;

• malleolar fracture as part of polytrauma [1 – 3, 5].

Indications for emergency hospitalization in case of a malleolar fracture are determined based on the presence in the patient of:

1. complaints characteristic of a malleolar fracture;

2. characteristic clinical signs of a malleolar fracture;

3. radiological signs of a malleolar fracture.

Indications for patient discharge from the hospital:

1. Internal fixation of the fracture with hardware or stabilization with an external fixation device has been performed, or adequate plaster immobilization has been achieved during conservative treatment.

2. The first stage of rehabilitation has been completed.

3. There is no acute infectious process.

4. Refusal by the patient or their guardians (in cases of legally established patient incompetence) to continue inpatient treatment (the reason for refusal must be documented in medical records with the personal signature of the patient or their guardians).

7. Additional Information

No additional information is required.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Belenky I.G., MD, Associate Professor, Saint Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze, Saint Petersburg, member of ATOR.

2. Bozhkova S.A., MD, Vreden National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, St. Petersburg, member of ATOR.

3. Geroyeva I.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

4. Kenis V.M., MD, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg.

5. Kleymenova E.B., MD, Professor, Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Russian Ministry of Health, Moscow.

6. Maiorov B.A., PhD, Saint Petersburg I.I. Janelidze Research Institute of Emergency Medicine, Pavlov University, Saint Petersburg, member of ATOR.

7. Nazarenko A.G., MD, Professor of the RAS, Director of the Priorov National Medical Research Center of Traumatology and Orthopedics of the Ministry of Health of the Russian Federation, Moscow, Vice President of ATOR.

8. Otdelenov V.A., PhD, Priorov National Medical Research Center of Traumatology and Orthopedics of the Russian Ministry of Health, Moscow.

9. Sapogovsky A.V., PhD, Turner National Medical Research Center for Children's Orthopedics and Trauma of the Russian Ministry of Health, St. Petersburg.

10. Sergeev G.D., PhD, Saint Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze, Saint Petersburg, member of ATOR.

Conflict of interest.

The working group for writing these clinical guidelines has no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Trauma and orthopedic surgeons

2. Surgeons

3. Pediatric surgeons

4. General practitioners

5. Medical rehabilitation physicians

Stages of evaluating the levels of evidence and grades of recommendation:

1. Definition of search and selection criteria for publications on clinical trials (CT) regarding the efficacy and/or safety of the medical intervention described in the recommendation statement.

2. Systematic search and selection of CT publications in accordance with the previously defined criteria.

Systematic search and selection of clinical trial publications:

The evidence base for the recommendations consisted of publications retrieved via information retrieval in the following databases: Central Scientific Medical Library (CSML) "Russian Medicine", MEDLINE (US NLM), and COCHRANE Library; scientific electronic libraries eLibrary.ru and "CyberLeninka"; as well as on the Internet using Yandex, Google, and Google Scholar search engines, by reviewing leading specialized peer-reviewed domestic medical journals on the subject and treatment guidelines for fractures from the international Association for Osteosynthesis AO/ASIF.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions).

Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions).

Table 3. Scale for grading the levels of evidence (LE) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Appendix A3.1. Guidelines for pain management in major musculoskeletal trauma (surgical interventions for long bone fracture fixation or complex articular fracture, extensive soft tissue trauma, major surgery, etc.) in adults

The table presents analgesic medications and dosing regimens in accordance with the Clinical Guide for Pain Management in Acute Musculoskeletal Trauma [146].

Appendix A3.2. Guidelines for pain management in musculoskeletal trauma without surgery (closed fractures, superficial wounds, etc.) in adults

Appendix A3.3. Recommendations for Postoperative Analgesia in Children

¹ Morphine** is preferred for children under 12 years of age when opioid analgesics are indicated, as the use of tramadol** is associated with a higher risk of adverse reactions [137, 138].

² Not recommended for use in children, as its metabolite accumulates in the body and provokes seizures with repeated administration [139].

Appendix A3.4 Recommended intervals between prophylactic administration of anticoagulants and neuraxial interventions in adult patients [145]

It should be noted that spinal or epidural anesthesia can be performed only 12 hours after the administration of a dose of low-molecular-weight heparins B01AB and no earlier than 4–6 hours after the administration of unfractionated heparin from the B01AB group (while aPTT or ACT values must be within the normal range) [94].

Appendix A3.5 Recommended dosing regimen of low-molecular-weight heparins for the prophylaxis of high-risk VTE in conservative treatment and orthopedic surgery in adult patients at high risk for VTE

Appendix A3.6 Bleeding risk factors in children aged 6 months to 18 years

Notes:

1. If the patient meets at least one "NOT recommended" criterion, avoid pharmacoprophylaxis, as the risk outweighs the benefit.

2. If the patient has at least one relative contraindication criterion, consider withholding pharmacoprophylaxis.

3. Consider a hematology consultation if the patient is at high risk for VTE with a high bleeding risk [123].

4. Uncontrolled hypertension is defined as systolic or diastolic blood pressure above the 95th percentile for age, height, and sex [124].

5. Coagulopathy is defined as INR > 1.5, aPTT > 44 s, fibrinogen < 100 g/dL, or platelets < 50,000/μL.

Appendix A3.7 VTE risk factors in children aged 6 months to 18 years

Notes:

• Decreased mobility compared to baseline or inability to participate in physical therapy.

• Central venous access device is defined as a non-tunneled catheter, tunneled catheter, or central venous catheter.

• A massive burn is defined as a burn involving more than 50% of the body surface area.

• Major surgical interventions include operations lasting more than 45 minutes.

• Critically ill patients are defined as those admitted to an intensive care unit or critical care unit (requiring inotropic support, mechanical ventilation).

• Thrombophilic conditions include antithrombin defects, protein C or S deficiency, Factor V Leiden, or prothrombin gene mutation.

• Active malignancy is defined as receiving chemotherapy/radiation therapy within the preceding 6 months.

• Active inflammatory disease includes Kawasaki disease, inflammatory bowel disease, systemic lupus erythematosus, or nephrotic syndrome.

• Estrogen therapy includes oral contraceptives, estrogen replacement therapy, or use within the past 2 weeks.

• Obesity is defined as a BMI above the 95th percentile for age.

Key:

Low VTE risk:

• No altered mobility and 0-1 risk factors

Moderate VTE risk:

• No mobility impairment and 2-3 risk factors

• Altered mobility and 0-1 other risk factors

High VTE risk:

• No mobility impairment and ≥4 risk factors

• Altered mobility and ≥2 other risk factors

Thromboprophylaxis recommendation

Appendix B. Physician Action Algorithms

Appendix B1. Physician action algorithms upon admission of a patient with suspected distal tibia fracture

Appendix B2. Assessment of Cardiovascular Surgical Risk

Notes and abbreviations:

CVRF – cardiovascular risk factors (arterial hypertension, smoking, dyslipidemia (elevated total cholesterol >4.9 mmol/L and/or LDL cholesterol >3 mmol/L and/or HDL cholesterol <1.0 mmol/L in men, <1.2 mmol/L in women, and/or triglycerides >1.7 mmol/L), diabetes mellitus, family history of premature cardiovascular disease (<55 years for men and <65 years for women);

CVD – cardiovascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease, chronic heart failure, pulmonary hypertension, valvular heart disease, cardiomyopathies);

rRCRI - reconstructed RCRI index (See Appendix 15.2);

FS – functional status (the patient's ability to climb 2 flights of stairs independently without stopping before the injury).

*- regional vascular center or specialized cardiological department.

Appendix C. Patient Information

Ankle fractures are injuries requiring specialized treatment in a trauma department (if there are indications for surgical treatment) or at a trauma center. Conservative treatment of such injuries is possible only for non-displaced fractures. This type of treatment involves immobilization with a plaster cast or its alternatives. Its main disadvantage is the increased duration of treatment and the need for prolonged rehabilitation, as immobilization results in knee and ankle joint contractures. Surgical treatment is indicated for all displaced fractures. Plates of various configurations, screws, intramedullary nails, and external fixation devices in various configurations can be used to treat ankle fractures. Treatment can be single-stage (for isolated closed fractures and satisfactory soft tissue condition) and two-stage, where the fracture is first temporarily fixed with an external fixator followed by conversion to internal fixation (in multiple and polytrauma, severe open fractures, and significant soft tissue injury). Ankle fractures in most cases are intra-articular fractures that require complete restoration of the articular surface anatomy. For this purpose, it is usually necessary to perform open reduction of the fracture site and align the fragments under direct vision. In all cases, one should strive to achieve stable osteosynthesis that does not require additional external immobilization after surgery. This makes it possible to start early rehabilitation treatment.

Rehabilitation treatment should be started immediately after surgery. It consists of passive and active movements in the lower extremity joints, physiotherapeutic procedures, and exercises aimed at normalizing the trophic state of the damaged soft tissues and bone. The timing of weight-bearing on the extremity may vary depending on the nature of the fracture and the method of fixation. Following plate osteosynthesis of fractures, weight-bearing is permitted no earlier than 4–6 weeks postoperatively.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Caprini Risk Assessment Scale for Venous Thromboembolism (Caprini J.)

Russian title: Caprini Individual Risk Assessment Scale for Venous Thromboembolism

Original title: Caprini Score for Venous Thromboembolism

Source: Lobastov K.V., Barinov V.E., Schastlivtsev I.V., Laberko L.A. Caprini scale as a tool for individual risk stratification of postoperative venous thromboembolism in the high-risk group. Pirogov Russian Journal of Surgery. 2014; (12):16-23.

Type: scale

Purpose: assessment of venous thromboembolism risk

Content (template):

1 point

Age 41–60 years

Lower extremity edema

Varicose veins

Body mass index over 25 kg/m2

Minor surgery

Sepsis (within 1 month)

Serious pulmonary disease (including pneumonia within 1 month)

Oral contraceptive use, hormone replacement therapy

Pregnancy and postpartum period (up to 1 month)

History of unexplained stillbirths, spontaneous abortions (≥3),

Premature birth with preeclampsia or intrauterine growth restriction

Acute myocardial infarction

Chronic heart failure (within 1 month)

Bed rest in a non-surgical patient

History of inflammatory bowel disease

Major surgery within the past 1 month

Chronic obstructive pulmonary disease

2 points

Age 61–74 years

Arthroscopic surgery

Malignant neoplasm105

Laparoscopic surgery (duration > 45 min)

Bed rest > 72 h

Limb immobilization (within 1 month)

Central venous catheterization

Major surgery (duration > 45 min)

3 points

Age > 75 years

Personal history of VTE

Family history of VTE

Factor V Leiden mutation

Prothrombin G20210A mutation

Hyperhomocysteinemia

Heparin-induced thrombocytopenia

Elevated anticardiolipin antibodies

Lupus anticoagulant

5 points

Stroke (< 1 month)

Multiple trauma (< 1 month)

Major joint arthroplasty

Femur and lower leg fractures (< 1 month)

Spinal cord injury/paralysis (< 1 month)

Key: Depending on the score obtained from history taking and patient examination, the patient is assigned to a specific risk group:

• low risk: 0–1 points;

• moderate risk: 2 points;

• high risk: 3–4 points;

• very high risk: 5 points or more

Appendix G2. Revised Cardiac Risk Index (rRCRI)

Russian title: Reconstructed Revised Cardiac Risk Index for noncardiac surgical procedures

Original title: Reconstructed Revised Cardiac Risk Index (rRCRI)

Source: Davis C., Tait G., Carroll J. et al. The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can. J. Anaesth. 2013; 60(9): 855-863.

Type: scale

Purpose: prediction of the risk of perioperative cardiac complications in noncardiac surgery: myocardial infarction, pulmonary edema, ventricular fibrillation or cardiac arrest, complete AV block.

Content:

1. High-risk surgery (intrathoracic, intra-abdominal, or suprainguinal vascular surgery) – 1 point.

2. Ischemic heart disease (myocardial infarction, positive stress test, angina pectoris, nitroglycerin use, pathological Q wave on ECG) – 1 point.

3. Heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, bilateral pulmonary rales, gallop rhythm, pulmonary congestion on chest X-ray) – 1 point.

4. TIA/Stroke – 1 point.

5. Creatinine clearance <30 ml/min - 1 point

Scoring:

• total score of 0 – low risk of cardiovascular complications;

• a total score of 1 – moderate risk of cardiovascular complications;

• a total score of 2 or more – high risk of cardiovascular complications.

Notes:

The RCRI index was developed in 1977 [98] to predict the risk of perioperative cardiac complications in noncardiac surgery. It was validated in the Lee study [99], and in 2013 [100] it was revised and re-validated based on clinical risk factors (the feature "creatinine level >176.8 µmol/l" in the scale was replaced by "creatinine clearance <30 ml/min"; the clinical feature "insulin-requiring diabetes mellitus" was removed), which is why it is called the reconstructed index. It includes 5 parameters, each assigned 1 point. This particular version of the index is recommended by the Russian Society of Cardiology [30].