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. 2026 Jul 6;18(8):1623–1630. doi: 10.1111/os.70372

Morphological Study of Weber Type A Lateral Malleolar Fractures

Chuhan Chen 1,2,3, Ruizhi Cai 1,2,3, Peng Qi 4,5, Hao Lu 1,2,3, Duosi Jiang 6, Yizhuo Fang 6, Jingtian Li 1,2,3, Chengbo Du 1,2,3, En Wu 7, Hailin Xu 1,2,3,✉
PMCID: PMC13398705  PMID: 42410620

ABSTRACT

Objective

Morphological studies of Weber Type A lateral malleolar fractures (LMFs) are scarce, and no classification criteria exist specifically for this fracture type. Therefore, our objective is to describe the distribution of Weber Type A LMF and propose a classification based on three‐dimensional computed tomography (CT) and fracture mapping techniques.

Methods

We retrospectively reviewed 586 patients presenting with lateral malleolar fractures at our hospital between June 2016 and May 2024. CT data were reconstructed and reduced using software, and fracture lines were delineated. Fracture lines from all patients were superimposed to generate fracture maps and heatmaps. Fracture section area (FSA) was also measured for each case. Using the Kolmogorov–Smirnov test to assess the normality of the data distribution and the Kruskal–Wallis test to compare the FSA values among different fracture subtypes.

Results

A total of 81 Weber type A LMFs were included. Based on the fracture morphology and its relationship with the fibular obscure tubercle (FOT) and inferior tip of the fibula (ITF), Weber type A LMFs were classified into three types: Type I: Anteroinferior (25 cases, 30.9%); Type II: Posteroinferior (32 cases, 39.5%); Type III: Metaphyseal (24 cases, 29.6%).

Conclusions

This study revealed the morphological characteristics of Weber type A LMF, enhanced understanding of the underlying injury mechanisms, and provided guidance for making diagnostic and therapeutic decisions.

Keywords: Anterior Talofibular Ligament, Calcaneofibular Ligament, Fracture Mapping, Weber Type A Lateral Malleolar Fractures

We created a fracture map of 81 patients with Weber Type A lateral malleolar fractures and classified it into three types based on its relationship with the inferior tip of the fibula and fibular obscure tubercle, which is the bony landmark correlated with the anterior talofibular ligament and calcaneofibular ligament.

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1. Introduction

Ankle fractures are among the most common traumatic fractures in adults, accounting for approximately 6%–10% of all fractures [1, 2]. Among these, approximately 90% involve the lateral malleolus [3, 4, 5]. Current classification systems for lateral malleolar fractures (LMFs) primarily include the Lauge‐Hansen classification, Danis‐Weber classification, and the AO/OTA (AO Foundation/Orthopedic Trauma Association) classification [6]. The Danis‐Weber classification is the most commonly used due to its high reproducibility and interobserver agreement [7]. Based on the position of the distal fibular fracture relative to the tibiofibular syndesmosis, the Danis‐Weber classification divides ankle fractures into three types: type A (below the syndesmosis), type B (at the level of the syndesmosis), and type C (above the syndesmosis) [4].

However, none of the aforementioned classifications adequately capture the morphology of LMF. The Lauge‐Hansen classification is based on the deforming force and the foot position at the time of injury, while Danis‐Weber and AO/OTA classifications are based solely on fracture location without describing fracture morphology [4]. In recent years, the morphology of Weber type B LMF has been characterized using various methods. Nevertheless, relatively little morphological research has been conducted on Weber type A or C fractures [8, 9, 10, 11].

With continuous advancements in CT technology, diagnosis accuracy for LMF has improved [12], facilitating morphological studies of the rarely investigated Weber type A LMF. Fracture mapping, which projects multiple fracture lines onto a standard template via three‐dimensional reconstruction, was first applied to the scapula by Armitage et al. [13] in 2009 and has since been adapted for various fracture types [14]. It can provide an intuitive representation of fracture morphology.

The objectives of this study were: (i) to characterize the morphological features of Weber type A LMF using three‐dimensional CT data and fracture mapping techniques; (ii) to propose a classification for Weber type A LMF; and (iii) to speculate the associated injury mechanisms.

2. Methods

2.1. Subjects

This retrospective study reviewed 586 patients with LMF who presented to our hospital between June 2016 and May 2024. Inclusion criteria were: (1) completion of ankle CT scanning; and (2) radiographic confirmation of a Danis‐Weber type A LMF. Exclusion criteria were: (1) history of ankle surgery or deformity; (2) pathological fractures; and (3) presence of old fractures. Informed consent was obtained from all of the participants, and the study was approved by the institutional review board of our institution (2024PHB161). Ultimately, 81 patients who met the inclusion criteria were enrolled. All the participants have signed the informed consent.

2.2. Fracture Mapping

Three‐dimensional ankle CT data were imported into Mimics Medical V21.0 software (Materialize, Belgium). Fracture fragments were reconstructed and reduced. The reconstructed models were processed using 3‐Matic 12.0 software (Materialize, Belgium) to delineate fracture lines, which were then superimposed onto a standard template.

2.3. Observation Indicators

Fracture section area (FSA) was measured for each patient using Mimics Medical V21.0 software. For each fracture, we selected the view showing the maximum cross‐sectional area and measured the area of the fracture fragments in that view (Figure 1).

FIGURE 1.

FIGURE 1

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Measurement of the FSA (the range of the FSA is highlighted by the red circle).

2.4. Data Analysis

Statistical analyses were performed using SPSS 25.0. The Kolmogorov–Smirnov test was used to assess normality. For normally distributed data, independent samples t‐tests were used to compare differences. For non‐normally distributed data, nonparametric tests were applied. The Kruskal–Wallis test was used to compare the FSA values among different fracture subtypes. A p‐value < 0.05 was considered statistically significant.

3. Results

3.1. Patient Characteristics and General Fracture Patterns

A total of 81 patients with Weber type A malleolar fractures were included. The mean age of the enrolled patients was 47.4 years (range: 18–75 years), including 27 males (33.3%) and 54 females (66.6%). There were 44 cases (54.3%) of right foot involvement and 37 cases (45.7%) of left foot involvement. The enrolled patients included 74 cases (91.4%) of Weber type A1 fractures, five cases (6.2%) of type A2 fractures, and two cases (2.4%) of A3 fractures. Fracture maps and heatmaps for all patients are shown in Figure 2. Fracture hotspots (red areas in Figure 2) were observed around the fibular obscure tubercle (FOT) and the inferior tip of the fibula (ITF), indicating a dense distribution of fracture lines near these bony landmarks.

FIGURE 2.

FIGURE 2

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Fracture mapping and heatmap of Weber type A lateral malleolar fractures. (A) heatmap (B) fracture mapping.

3.2. Proposed Classification System

Based on the relationship between fracture line distribution and both the FOT and ITF, Weber type A LMF was classified into the following three types: Type I: Anteroinferior (25 cases, 30.9%); Type II: Posteroinferior (32 cases, 39.5%); Type III: Metaphyseal (24 cases, 29.6%). The classification criteria are detailed below. The Kruskal–Wallis test revealed a significant difference in FSA values across the three fracture types (H = 42.872, p < 0.001). Specifically, the median FSA with interquartile range was 59.819 mm2 (35.6, 89.1) for type I, 71.707 mm2 (42.7, 201.2) for type II, and substantially larger at 302.818 mm2 (213.2, 369.7) for type III.

3.3. Morphological Characteristics of Each Fracture Subtype

3.3.1. Type I: Anteroinferior

Anteroinferior fractures originate above the FOT and terminate anterior to the ITF. Its mean FSA is 65.6 mm2. Only two patients had an FSA below 20 mm2, with a minimum of 8.9 mm2. Fracture maps and heatmap for anteroinferior fractures are shown in Figure 3, and a typical case of Type I fracture is shown in Figure 4. The fracture line in Type I fractures forms a distinct fracture ring around the FOT.

FIGURE 3.

FIGURE 3

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Fracture mapping and heatmap of type I fractures. (A) heatmap (B) fracture mapping.

FIGURE 4.

FIGURE 4

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A typical case of type I fracture (a: Before surgery; b: after surgery). This is a Weber type A fracture involving only the lateral malleolus. The surgeon excised the avulsion fracture fragment and performed an ATFL reconstruction.

3.3.2. Type II: Posteroinferior

Posteroinferior fractures originate posterior to the FOT and terminate posterosuperior to the ITF. The fracture maps and heatmap for posteroinferior fractures are presented in Figure 5, and a typical case of type II fracture is shown in Figure 6. The fracture lines show a densely distributed zone between the FOT and ITF, but do not form a complete fracture ring above the ITF. The mean FSA is 113.66 mm2. FSA values in patients with posteroinferior fractures do not follow a normal distribution, ranging from 27.02 mm2 to 258.29 mm2. Alarger FSA is associated with more extensive involvement of the medial aspect of the lateral malleolus.

FIGURE 5.

FIGURE 5

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Fracture mapping and heatmap of type II fractures. (A) heatmap (B) fracture mapping.

FIGURE 6.

FIGURE 6

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A typical case of type II fracture (a: Before surgery; b: after surgery. This is a bimalleolar fracture involving both the lateral and medial malleolus, classified as a Weber type A and supination‐adduction fracture. The patient underwent open reduction and internal fixation with a screw to repair the lateral malleolus.).

3.3.3. Type III: Metaphyseal

Metaphyseal fractures originate above the FOT and terminate posterosuperior to the ITF. The fracture maps and heatmap for metaphyseal fractures are shown in Figure 7, and a typical case of type III fracture is shown in Figure 8. The fracture lines in metaphyseal fractures exhibit a relatively dispersed distribution pattern without any distinct concentrated zone. The mean FSA is 290.04 mm2.

FIGURE 7.

FIGURE 7

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Fracture mapping and heatmaps of metaphyseal fractures. (A) Heatmap. (B) fracture mapping.

FIGURE 8.

FIGURE 8

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A typical case of type III fracture (a: Before surgery; b: after surgery. This is a Weber type A and supination‐adduction malleolar fracture. The patient underwent open reduction and internal fixation with a plate to repair the lateral malleolus.).

4. Discussion

4.1. Main Findings

In this study, we performed a comprehensive morphological analysis of Weber type A LMF using fracture mapping techniques. We identified three distinct fracture patterns based on their anatomical relationships with the FOT and ITF. Our classification focuses on the specific injury patterns of the lateral malleolus in Weber type A malleolar fractures, thereby providing valuable insights for clinical decision‐making.

4.2. Morphological Classification and Its Clinical Characteristics

Historically, morphological studies of Weber type A LMF have been limited. Statistics indicate that Weber type A fractures account for only 20%–24% of all ankle fractures, with an even lower proportion among surgically treated patients [15, 16, 17]. Our study reviewed 586 patients with LMF and ultimately included 81 with Weber type A LMF in the analysis, which is consistent with previous reports. Research has shown that Weber type A2 and A3 fractures constitute only 13% of all Weber type A fractures, a proportion that aligns with the distribution observed in our study [5].

The stability of the lateral malleolus is primarily provided by the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) [18]. It is indicated that the ATFL and CFL are located on the anterior border of distal fibula at a distance of 10–13.8 and 5.3–8.5 mm proximal to the tip of the fibula, respectively [18]. The FOT is recognized as a highly relevant and reliable bony landmark correlated with the attachment points of both ligaments [19]. Consequently, in this study, we used the FOT and ITF as anatomical landmarks for classification, dividing Weber type A LMF into three types. Compared with the AO/OTA or Danis‐Weber classifications, which primarily focus on fracture level, our morphological system provides specific guidance on fragment management and fixation choice, thereby providing valuable insights for clinical decision‐making.

Type I (anteroinferior) fractures have the smallest mean FSA, with fracture lines distributed from anterosuperior to posteroinferior. The fracture lines in type I fractures form a distinct fracture ring around the FOT, suggesting a relatively consistent injury pattern for this type. We propose that it is an avulsion fracture caused by ATFL injury. Surgical and conservative management yield similar outcomes for this fracture type. Regarding surgical treatment, the smallest diameter of full threaded screws currently available to us is 2.5 mm (approximate 4.9 mm2 in cross‐sectional area). We believe that screws cannot be used to stabilize comminuted fractures or fractures with an FSA less than four times the screw area, as this may cause further breakage of the fracture fragments. For these cases, the fragments should be removed directly, followed by reconstruction of the ATFL. Regardless of the surgical technique chosen, functional recovery and gait biomechanics after fracture fixation are important [20].

The FSA values for type II (posteroinferior) fractures are not normally distributed, suggesting that the forces causing posteroinferior fractures may be complex. As noted, the fracture line in type II fractures shows a densely distributed zone between the FOT and ITF, but fails to form a complete fracture ring above the ITF. This may indicate that type II fractures have a more concentrated fracture origin, with a relatively diverse fracture end distribution. The fracture lines in type II fractures are distributed from anteroinferior to posterosuperior. We propose that this type of fracture is primarily caused by CFL injury.

Previous studies have suggested that the ATFL is the most commonly injured ligament in lateral ankle sprains, with only 20% of cases involving concomitant CFL injury [21, 22]. However, in our study, the proportion of type II fractures was higher (39.5%). This suggests that patients with fractures may have a higher probability of CFL injury than those with isolated ankle sprains. This finding alerts clinicians to the potential of concomitant ATFL injury in type II fractures, even when ATFL injury does not result in fracture. With a minimum FSA of 30.7 mm2 FSA, all type II fractures in our series can be treated with screw fixation. In the traditional supination‐adduction model, tension on the CFL is relatively low, requiring substantial force to cause injury. In contrast, with the foot in a neutral or dorsiflexed position, ligament tension is higher, and less force is needed to cause CFL injury. This aligns with the wide variation in FSA distribution observed in type II fractures, suggesting that different injury mechanisms may lead to CFL injury in this fracture type. Armiger et al. [23] found that applying an external rotation force while the foot is in a pronated position can also produce a short oblique fracture of the distal fibula, which is consistent with our findings.

Type III (metaphyseal) fractures have the largest mean FSA, with horizontal fracture lines parallel to the metaphysis. We propose this fracture type results from combined injury to the ATFL and CFL, representing the highest‐energy injuries. However, surgery is not always required—indications depend on ankle stability, medial clear space, and bimalleolar or trimalleolar involvement [24]. For type III fractures, surgical treatment may involve screws and plates. Given the large fragment size of this fracture type, elastic locking intramedullary nails fixation is also a viable option [25]. Different methods of fracture fixation do not appear to significantly affect clinical outcomes [26]. Some biological adjuvants, such as teriparatide, may also aid in fracture healing [27]. In addition, certain anti‐inflammatory and antiedema strategies can help reduce postoperative pain and swelling, ultimately improving patient outcomes [28, 29].

4.3. Guidance of Clinical Treatment

Building upon the morphological and clinical characteristics of the classification described above, we propose specific therapeutic recommendations for each type.

Type I (anteroinferior) fractures: Conservative management is acceptable if the ATFL is intact or only mildly injured. However, if severe ATFL injury results in persistent functional impairment, arthroscopic excision of the fracture fragment combined with ATFL reconstruction is recommended.

Type II (posteroinferior) fractures: Concomitant CFL injury in addition to ATFL damage should be closely monitored. Larger fracture fragments may be managed with screw fixation, whereas smaller fragments can be treated with excision followed by ligament reconstruction.

Type III (metaphyseal) fractures: Given the significant size of the fracture fragments in this type, surgical intervention is generally required. Open reduction and internal fixation with a plate is considered an appropriate treatment choice.

4.4. Limitations and Strengths

The main strengths of this study are as follows. First, we used fracture mapping technology to visualize the morphology of Weber type A LMF and identified three predominant fracture patterns, providing an intuitive and reliable basis for classification. Second, given the absence of a dedicated classification system for Weber type A LMF, we propose the first three‐dimensional CT‐based classification system for this fracture type, thereby filling an important gap in the literature. Third, based on the relationship between the fracture patterns and ligamentous attachment sites, we inferred the potential injury mechanisms associated with each fracture type and provided corresponding treatment recommendations.

There are some limitations in our study. First, many patients without CT scans were excluded, resulting in a relatively small cohort. Second, the assessment relied solely on CT data, and the proposed ligament injury mechanisms were inferred from anatomical and biomechanical knowledge without validation by ultrasound or MRI. We plan to use ultrasound or MRI to validate our ligament injury hypothesis in future studies. Third, the study lacked clinical follow‐up, leaving the clinical prognosis for each classification unclear. A prospective follow‐up study will be conducted to validate the prognostic value of this classification system.

5. Conclusion

In conclusion, this study investigated the morphological manifestations of Weber type A LMF and revealed several important characteristics and injury patterns associated with this fracture type. First, anteroinferior fractures correlate with ATFL avulsion, exhibiting a consistent fracture pattern. Second, posteroinferior fractures are associated with CFL injury, although concomitant ATFL damage warrants vigilance. Third, diverse injury mechanisms may account for the varied presentations of posteroinferior fractures. Fourth, metaphyseal fractures result from combined injury to the ATFL and CFL. Our proposed classification of Weber type A LMF enhances understanding in injury mechanisms and provides guidance in making diagnostic and therapeutic decisions.

Author Contributions

Chuhan Chen: conceptualization, methodology, investigation, formal analysis, resources, writing – original draft, writing – review and editing. Chengbo Du: investigation. Duosi Jiang: investigation. En Wu: investigation. Peng Qi: investigation, formal analysis, methodology, resources. Yizhuo Fang: investigation. Ruizhi Cai: methodology, investigation, formal analysis, resources. Hailin Xu: conceptualization, writing – review and editing, funding acquisition, supervision. Hao Lu: conceptualization, writing – review and editing, resources, supervision, funding acquisition. Jingtian Li: investigation.

Funding

This study is supported by National Key Research and Development Program of China (2022YFC2504302), Peking University People's Hospital Scientific Research Development Funds (RDGS2024‐07) and Beijing Traditional Chinese Medicine Science and Technology Development Fund Project (BJYD‐2025‐12).

Disclosure

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors are in agreement with the manuscript.

Ethics Statement

Informed consent to participate was obtained from all participants, and this study was approved by the institutional review board of our hospital (2024PHB161). This study was conducted in accordance with the Declaration of Helsinki.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgments

The authors have nothing to report.

Chen C., Cai R., Qi P., et al., “Morphological Study of Weber Type A Lateral Malleolar Fractures,” Orthopaedic Surgery 18, no. 8 (2026): 1623–1630, 10.1111/os.70372.

Chuhan Chen as co‐first author ranked first, and Ruizhi Cai as co‐first author ranked second.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  • 1. Bilge O., Dündar Z. D., Atılgan N., et al., “The Epidemiology of Adult Fractures According to the AO/OTA Fracture Classification,” Ulusal Travma ve Acil Cerrahi Dergisi 28, no. 2 (2022): 209–216, 10.14744/tjtes.2020.26374. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Pavić R., Hnatešen D., and Margetić P., “Epidemiology of Adult Fractures in Eastern Croatia by Cause of Injury, Fracture Location and Type of Treatment,” Acta Clinica Croatica 56, no. 3 (2017): 494–504, 10.20471/acc.2017.56.03.17. [DOI] [PubMed] [Google Scholar]
  • 3. Court‐Brown C. M., McBirnie J., and Wilson G., “Adult Ankle Fractures—An Increasing Problem?,” Acta Orthopaedica Scandinavica 69, no. 1 (1998): 43–47, 10.3109/17453679809002355. [DOI] [PubMed] [Google Scholar]
  • 4. Aiyer A. A., Zachwieja E. C., Lawrie C. M., and Kaplan J. R. M., “Management of Isolated Lateral Malleolus Fractures,” Journal of the American Academy of Orthopaedic Surgeons 27, no. 2 (2019): 50–59, 10.5435/jaaos-d-17-00417. [DOI] [PubMed] [Google Scholar]
  • 5. Han S. M., Wu T. H., Wen J. X., et al., “Radiographic Analysis of Adult Ankle Fractures Using Combined Danis‐Weber and Lauge‐Hansen Classification Systems,” Scientific Reports 10, no. 1 (2020): 7655, 10.1038/s41598-020-64479-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. Lauge‐Hansen N., “Fractures of the Ankle. III. Genetic Roentgenologic Diagnosis of Fractures of the Ankle,” American Journal of Roentgenology, Radium Therapy, and Nuclear Medicine 71, no. 3 (1954): 456–471. [PubMed] [Google Scholar]
  • 7. Ramos L. S., Gonçalves H. M., Freitas A., Oliveira M. P., Lima D. M. S., and Carmargo W. S., “Evaluation of the Reproducibility of Lauge‐Hansen, Danis‐Weber, and AO Classifications for Ankle Fractures,” Revista Brasileira de Ortopedia (Sao Paulo) 56, no. 3 (2021): 372–378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Wang W. B. and Chang S. M., “Three‐Dimensional Morphological Study of Type B Lateral Malleolar Fractures With Special Reference to the End‐Tip Location of Proximal Apexes,” Frontiers in Bioengineering and Biotechnology 11 (2023): 1152775, 10.3389/fbioe.2023.1152775. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Cai R., Feng S., Chen C., Lu H., and Xu H., “Morphological and Clinical Study of Lateral Malleolus Fractures Based on Fracture Mapping: A Retrospective Study,” Journal of Orthopaedic Surgery and Research 19, no. 1 (2024): 894, 10.1186/s13018-024-05424-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Zeng J., Xu C., Xu G., et al., “Evaluation of Ankle Fractures in 228 Patients From a Single Center Using Three‐Dimensional Computed Tomography Mapping,” Frontiers in Bioengineering and Biotechnology 10 (2022): 855114, 10.3389/fbioe.2022.855114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Cao M. M., Zhang Y. W., Hu S. Y., et al., “3D Mapping of the Lateral Malleolus Fractures for Predicting Syndesmotic Injuries in Supination External Rotation Type Ankle Fractures,” Journal of Foot and Ankle Surgery 61, no. 6 (2022): 1197–1202, 10.1053/j.jfas.2022.01.026. [DOI] [PubMed] [Google Scholar]
  • 12. Xue P., Chen X., Chen S., and Shi Y., “The Value of CT 3D Reconstruction in the Classification and Nursing Effect Evaluation of Ankle Fracture,” Journal of Healthcare Engineering 2021 (2021): 9596518, 10.1155/2021/9596518. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Armitage B. M., Wijdicks C. A., Tarkin I. S., et al., “Mapping of Scapular Fractures With Three‐Dimensional Computed Tomography,” Journal of Bone and Joint Surgery. American Volume 91, no. 9 (2009): 2222–2228, 10.2106/jbjs.H.00881. [DOI] [PubMed] [Google Scholar]
  • 14. Liu J., Zhang Z., Qu J., and Piao C., “Progress of Fracture Mapping Technology Based on CT Three‐Dimensional Reconstruction,” Frontiers in Bioengineering and Biotechnology 12 (2024): 1471470, 10.3389/fbioe.2024.1471470. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Rydberg E. M., Wennergren D., Stigevall C., Ekelund J., and Möller M., “Epidemiology of More Than 50,000 Ankle Fractures in the Swedish Fracture Register During a Period of 10 Years,” Journal of Orthopaedic Surgery and Research 18, no. 1 (2023): 79, 10.1186/s13018-023-03558-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Juto H., Nilsson H., and Morberg P., “Epidemiology of Adult Ankle Fractures: 1756 Cases Identified in Norrbotten County During 2009–2013 and Classified According to AO/OTA,” BMC Musculoskeletal Disorders 19, no. 1 (2018): 441, 10.1186/s12891-018-2326-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Vieira Cardoso D., Dubois‐Ferrière V., Gamulin A., et al., “Operatively Treated Ankle Fractures in Switzerland, 2002–2012: Epidemiology and Associations Between Baseline Characteristics and Fracture Types,” BMC Musculoskeletal Disorders 22, no. 1 (2021): 266, 10.1186/s12891-021-04144-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Matsui K., Takao M., Tochigi Y., Ozeki S., and Glazebrook M., “Anatomy of Anterior Talofibular Ligament and Calcaneofibular Ligament for Minimally Invasive Surgery: A Systematic Review,” Knee Surgery, Sports Traumatology, Arthroscopy 25, no. 6 (2017): 1892–1902, 10.1007/s00167-016-4194-y. [DOI] [PubMed] [Google Scholar]
  • 19. Matsui K., Oliva X. M., Takao M., et al., “Bony Landmarks Available for Minimally Invasive Lateral Ankle Stabilization Surgery: A Cadaveric Anatomical Study,” Knee Surgery, Sports Traumatology, Arthroscopy 25, no. 6 (2017): 1916–1924, 10.1007/s00167-016-4218-7. [DOI] [PubMed] [Google Scholar]
  • 20. Falzarano G., Pica G., Medici A., et al., “Foot Loading and Gait Analysis Evaluation of Nonarticular Tibial Pilon Fracture: A Comparison of Three Surgical Techniques,” Journal of Foot and Ankle Surgery 57, no. 5 (2018): 894–898, 10.1053/j.jfas.2018.03.025. [DOI] [PubMed] [Google Scholar]
  • 21. Gomes T. M., Oliva X. M., Viridiana Sanchez E., Soares S., and Diaz T., “Anatomy of the Ankle and Subtalar Joint Ligaments: What we Do Not Know About It?,” Foot and Ankle Clinics 28, no. 2 (2023): 201–216, 10.1016/j.fcl.2022.12.003. [DOI] [PubMed] [Google Scholar]
  • 22. Fong D. T., Hong Y., Chan L. K., Yung P. S., and Chan K. M., “A Systematic Review on Ankle Injury and Ankle Sprain in Sports,” Sports Medicine 37, no. 1 (2007): 73–94, 10.2165/00007256-200737010-00006. [DOI] [PubMed] [Google Scholar]
  • 23. Haraguchi N. and Armiger R. S., “A New Interpretation of the Mechanism of Ankle Fracture,” Journal of Bone and Joint Surgery. American Volume 91, no. 4 (2009): 821–829, 10.2106/jbjs.G.01288. [DOI] [PubMed] [Google Scholar]
  • 24. Patel S. and Dionisopoulos S. B., “Current Concepts in Ankle Fracture Management,” Clinics in Podiatric Medicine and Surgery 41, no. 3 (2024): 519–534, 10.1016/j.cpm.2024.01.008. [DOI] [PubMed] [Google Scholar]
  • 25. Zhao Z., Zhao Y., Wang Y., et al., “Elastic Locking Intramedullary Nails Fixation in Trimalleolar Fractures,” Orthopaedic Surgery 17, no. 11 (2025): 3142–3150, 10.1111/os.70179. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Petruccelli R., Bisaccia M., Rinonapoli G., et al., “Tubular vs Profile Plate in Peroneal or Bimalleolar Fractures: Is There a Real Difference in Skin Complication? A Retrospective Study in Three Level I Trauma Center,” Medical Archives 71, no. 4 (2017): 265–269, 10.5455/medarh.2017.71.265-269. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Meccariello L., Cusano G., Meluccio A., Gigante A. P., and Matera L., “Evaluating Fracture Healing in Tibial Plafond Injuries: RUST Score Analysis After ORIF and MIPO With Adjuvant Teriparatide Therapy,” Journal of Foot and Ankle Surgery 65, no. 2 (2026): 61.e1–61.e8, 10.1053/j.jfas.2025.11.011. [DOI] [PubMed] [Google Scholar]
  • 28. Meccariello L., Bello A. I., Bove G., Gagliardo N., Raffaele D., and Matera L., “The Ion Resonance and Bromelain‐Vitamin C vs Bromelainvitamin C to Prevent Ankle Complications in Post‐Operative Bimalleolar Surgery,” Medicinski Glasnik 21, no. 1 (2024): 236–243, 10.17392/1691-23. [DOI] [PubMed] [Google Scholar]
  • 29. Rollo G., Russi V., and Meccariello L., “Effects of a Combination of Bromelain and Boswellia serrata Casperome on Swelling, Pain, Stiffness and Complications in Ankle Fracture,” Minerva Orthopedics 73, no. 6 (2022): 518–22, 10.23736/s2784-8469.20.04042-4. [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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