Foot & Ankle
Ankle Fracture
Non-Operative & Operative management
About Your Injury
An ankle fracture is a break in one or more of the bones forming the ankle joint — the fibula, tibia, or both. Ankle fractures range widely in severity, from simple stable fractures to complex, unstable injuries.
Non-Operative Management
Ankle fractures can often be safely and effectively managed without surgery. The decision is individualised to each patient, based on patient factors (age, comorbidities, occupation) and specific characteristics of the fracture (fracture pattern, displacement, joint congruity).
A major factor in deciding between operative and non-operative management is the presence of an associated ligament injury through the syndesmosis — the strong ligament complex joining the tibia and fibula just above the ankle joint. This can be difficult to assess on the initial X-rays, as it requires a stress X-ray taken while fully weight-bearing. You will often be discharged in a boot and encouraged to commence weight-bearing immediately, however the final decision on whether the fracture requires operative fixation and syndesmosis reconstruction is made at the 7–14 day mark, once weight-bearing X-rays can be performed.
Recovery Timeline
Days 0–7
Boot, weight-bearing encouraged as tolerated, elevation for swelling.
Days 7–14
Weight-bearing X-rays to assess the syndesmosis and confirm the final treatment plan — non-operative management continues if the joint remains stable under load.
Weeks 2–6
Continued protected weight-bearing in the boot; repeat X-ray to confirm the position is maintained.
Week 6
Transition out of the boot; physiotherapy for ankle movement and strength.
3–4 months
Return to normal walking and most daily activities.
4–6 months
Return to sport or heavy manual work once strength has recovered.
Follow-Up Schedule
7–14 days
Weight-bearing X-ray — the key appointment where the final decision between operative and non-operative treatment is confirmed.
6 weeks
X-ray to assess healing and progress weight-bearing.
3 months
Review of walking pattern and strength.
Operative Management
Unstable fractures, or those where the joint is no longer well aligned, are treated with surgery to restore normal ankle anatomy and allow safe healing.
The exact combination of fixation used depends on which structures are injured, and is confirmed at the time of surgery. A plate and screws are used to fix the fibula (the outer ankle bone) — the most common component of ankle fracture surgery. If the inner (medial) side of the ankle is also fractured (a 'bimalleolar' fracture), this is fixed with screws or a small plate as well. If the syndesmosis is unstable, this is reconstructed either with screws or a suture-button device ('tightrope'), which allows a small amount of natural give at the joint.
This procedure is performed under general anaesthetic, with local anaesthetic infiltration at the time of surgery for good pain control in the first 12–24 hours afterward. It is usually done as day surgery or with a single overnight stay.
Recovery Timeline
Weeks 0–2
Boot, protected and non-weight-bearing while the wound heals.
2 weeks onward
For most patients, weight-bearing as tolerated commences in the CAM boot.
6 weeks
X-ray to assess healing; transition out of the boot begins.
3–4 months
A gradual, protocol-based return to sport and heavy activity once fracture union is confirmed, guided by a good physiotherapist — not rushed, and progressed against objective milestones rather than a fixed date.
Follow-Up Schedule
2 weeks
Wound check and, for most patients, the start of weight-bearing in the boot.
6 weeks
X-ray to assess healing and progress weight-bearing.
3–4 months
Review of union and strength, with a gradual, protocol-based return to sport guided by a good physiotherapist.
Why Weight-Bear This Early?
Traditionally, ankle fractures were kept non-weight-bearing for 6 weeks after surgery. Dr Hogan favours a slightly faster rehabilitation in the right patient — starting protected weight-bearing at 2 weeks, supported by recent high-quality research (the WAX and INWN trials) showing this achieves similar or better functional outcomes than prolonged non-weight-bearing, without increasing complication rates. This faster approach isn't appropriate for every patient — more complex fracture patterns, diabetes, poor bone quality, or immunosuppression are examples of factors that may mean a more traditional, slower timeline is safer for you. Your individual timeline will be discussed with you.
Hardware Removal
Plates and screws are not routinely removed. Removal is only considered if hardware becomes symptomatic — for example, causing local irritation or discomfort with footwear.