A trimalleolar fracture is a severe ankle injury involving breaks in three distinct areas: the lateral malleolus (outer ankle), the medial malleolus (inner ankle), and the posterior malleolus (the back part of the shinbone). This fracture often leads to joint instability, making surgical intervention the standard course of treatment. Open reduction and internal fixation (ORIF) surgery is performed, using plates and screws to stabilize the fractures. This procedure results in one or more surgical incisions that will heal into scars.
The Surgical Incision and Initial Healing
Surgical incisions for a trimalleolar fracture allow direct access to the fractures. A common approach involves an incision on the outer ankle for the lateral malleolus and fibula, and another on the inner ankle for the medial malleolus. Depending on the posterior malleolus fragment’s size and displacement, a separate incision, possibly posterolateral or posteromedial, may also be required for proper fixation. Surgeons close these wounds with sutures or staples.
Maintaining a clean and dry wound environment is important during the initial healing phase. Patients must keep the surgical site protected, often covered by a splint or dressing, and avoid immersing the leg in water. Dressings and sutures are removed at the first post-operative appointment, around 10 to 14 days after surgery, once the skin edges have closed.
Long-Term Scar Management and Minimization
Once the surgical wound has closed, within two to four weeks, proactive scar management can begin to influence the scar’s appearance and flexibility. Scar massage can be initiated once the incision is strong enough, often around 4 to 6 weeks post-surgery. Applying firm, gentle pressure, either in circular motions, linear strokes along the scar, or perpendicular cross-friction motions, helps to break down disorganized collagen fibers and improve tissue pliability. Consistent massage, performed about 10 times along the scar twice daily, can also reduce stiffness and prevent the scar from adhering to underlying tissues.
Silicone products, available as adhesive sheets or topical gels, are advised for scar minimization. These products work by creating a hydrated environment over the scar, which helps to regulate collagen production and reduce tension at the wound site. Regular use of silicone sheets, worn for 12 to 24 hours daily over several months, can help flatten, soften, and reduce the redness and itching associated with new scars. They are effective in preventing the formation of raised scars.
Protecting the new scar from sun exposure is important in long-term management. Ultraviolet (UV) radiation can cause new scars to hyperpigment, meaning they become permanently darker than the surrounding skin. This discoloration can be long-lasting. Covering the scar with clothing or bandages, or applying a broad-spectrum sunscreen with an SPF of 30 or higher is recommended for at least one year post-surgery. Reapplying sunscreen every two hours when outdoors is important.
Scar Maturation and Final Appearance
Scar maturation is a gradual process. While the initial wound closure occurs within weeks, a scar can take anywhere from 6 months to 2 years, or even longer, to fully mature. During the early stages, new scars often appear red, pink, or even purple, and may feel raised or firm to the touch. This coloration is due to increased blood flow as the body works to rebuild tissue.
Over many months, the scar undergoes a remodeling phase where collagen fibers reorganize and strengthen. This process leads to a gradual fading of the color, transitioning from reddish hues to a paler pink, and eventually becoming a flatter, softer, and sometimes silvery line. Individual factors such as genetics, age, skin tone, and the specific surgical technique employed can all influence the scar’s ultimate texture and visibility.
Potential Scar-Related Complications
While most scars heal predictably, some individuals may experience abnormal scar formation. Hypertrophic scars are raised and thickened, but they remain confined within the boundaries of the original surgical incision. These scars often appear red or pink and may gradually flatten and fade over time, sometimes responding well to treatments like silicone products.
In contrast, keloid scars are more aggressive, extending beyond the original wound margins and continuing to grow into the surrounding healthy skin. Keloids can range in color from pink to purple or dark brown, may feel itchy or painful, and rarely shrink on their own. They are more challenging to treat and are more common in individuals with darker skin tones.
It is also common to experience altered sensation around the surgical site, such as numbness or tingling. This occurs because superficial nerves in the skin may be cut or damaged during the surgical procedure itself, or they can become compressed by developing scar tissue. While some nerve sensations may improve over time as nerves regenerate, complete resolution is not guaranteed and can take weeks to several years.
Another potential complication involves scar adhesions, where the scar tissue sticks to underlying structures like tendons, muscles, or even bone. This can restrict movement and cause discomfort. Regular scar massage and specific physical therapy exercises, often guided by a professional, are recommended to help prevent or alleviate adhesions by promoting tissue mobility and flexibility around the ankle joint.