A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. The trauma is sometimes accompanied by ligament damage and dislocation.The three aforementioned parts of bone articulate with the talus bone of the foot. Strictly speaking, there are only two malleoli (medial and lateral), but the term trimalleolar is used nevertheless and as such is a misnomer. The trimalleolar fracture is also known as cotton fracture. Treatment
Surgical repair using open reduction and internal fixation is generally required, and because there is no lateral restraint of the foot, the ankle cannot bear any weight while the bone knits. This typically takes six weeks in an otherwise healthy person, but can take as much as twelve weeks. Non-surgical treatment may sometimes be considered in cases where the patient has significant health problems or where the risk of surgery may be too great. References
Further reading
Weber, Martin (2004). "Trimalleolar Fractures with Impaction of the Posteromedial Tibial Plafond: Implications for Talar Stability". Foot & Ankle International. 25 (10): 716–27. doi:10.1177/107110070402501005. PMID 15566703. S2CID 43182738. Weber, Martin; Ganz, Reinhold (2003). "Malunion following Trimalleolar Fracture with Posterolateral Subluxation of the Talus — Reconstruction Including the Posterior Malleolus". Foot & Ankle International. 24 (4): 338–44. doi:10.1177/107110070302400406. PMID 12735377. S2CID 20888046. Bucholz, R. W.; Henry, S; Henley, M. B. (1994). "Fixation with bioabsorbable screws for the treatment of fractures of the ankle". The Journal of Bone and Joint Surgery. 76 (3): 319–24. doi:10.2106/00004623-199403000-00001.
Treatment
There have been few randomized treatment trials, due to the relative rarity of inflammatory myopathies. The goal of treatment is improvement in activities of daily living and muscle strength. Suppression of immune system activity (immunosuppression) is the treatment strategy. Patients with PM or DM almost always improve to some degree in response to treatment, at least initially, and many recover fully with maintenance therapy. (If there is no initial improvement from treatment of PM or DM, the diagnosis should be carefully re-examined.) There is no proven effective therapy for IBM, and most IBM patients will need assistive devices such as a cane, a walking frame or a wheelchair. The later in life IBM arises, the more aggressive it appears to be. Polymyositis and dermatomyositis
In severe cases of PM and DM with systemic signs, an initial three to five days on intravenous corticosteroid (methylprednisolone) may be used; but normally treatment begins with a single daily (after breakfast) high dose of oral corticosteroid (prednisone). After a month or so the strength of every second days dose is very gradually reduced over three to four months, to minimize the negative effects of the prednisone. When a high dose of prednisone cannot be reduced without losing muscle strength, or when prednisone is effective but it is producing significant complications, "steroid sparing" oral immunosuppressants such as azathioprine, mycophenolate mofetil, methotrexate and cyclosporine, may be used in combination with reduced prednisone.