Outline:  
Fracture of malleolus is very common in clinic. It mostly occurs in young adults and old people. And most cases are caused by indirect violence. Fracture of malleolus is classified into several types, the medial and the lateral monomalleolar, bimalleolar and trimalleolar fractures. According to the mechanism it may be divided into inversion, eversion, extorsion, lateral crush, vertical crush, plantar flexion and dorsal extension fractures. Clinically inversion fracture is frequently seen. And according to the degree of dislocation of fractures, the trauma may be divided into three grades: monomalleolar fracture as grade I, bimalleolar fracture with slight dislocation of talus as grade II, and trirnalleolar fracture with dislocation of talus as grade III.

Major points for diagnosis
1. The patient has a typical history of ankle trauma.
 
2. There is a marked pain of the ankle with failure of motion.
 
3. There is a swelling of the ankle with ecchymose. There may exist inversional, or eversional or rotatory deformity, tenderness and palpable bony crepitus, as well as dysfunction of the ankle joint.

4. X-ray film can reveal the location of fracture, the degree of displacement and the type of fracture.

Treatment:  
Fracture of malleolus is a kind of intra-articular fracture. In the treatment, it is essential that the articular surface should be kept smooth so as to prevent development of traumatic arthritis. Fractures with no displacement should only be treated by fixation in a neutral position for 3 or 4 weeks. For the fractures with displacement, precise reduction and effective fixation as well as early and reasonable functional exercises are demanded

Reduction:
The patient takes a horizontal position with the knee bent. An assistant nooses the popliteal fossa of the injured limb with his elbow, and then the operator grasps the heel and the dorsum of foot for pulling. It is necessary to let the ankle inverted for eversional injury, and to let the ankle everted for inversional injury. For the patients with separation of the lower tibiofibular joint, the operator squeezes and presses the medial and the lateral malleoli with the two palms facing each other. For the posterior malleolar fracture complicated by backward dislocation of talus, the operator holds the lower part of tibia to push it backward with one hand, and grasps the anterior part of the foot to pull it forward with the other hand. At the same time, the operator slowly makes the ankle join extended dorsoward so that the posterior malleolus is pulled down by taking advantage of tension of joint capsule. Or a long stocking can be put on the whole leg. The lower end of the stocking should be20 cm longer than the tip of the foot and bound up with traction cord for suspension sliding traction so that the weight of the limb can make reposition of posterior malleolus gradually .

Fixation:
Under the state of traction, two tower-shaped pads are put on the medial and the lateral malleoli and two ladder pads beneath them and then covered with cotton pads. Fractures with inversional or eversional deformity are treated by fixation of the ankle in a neutral position between two tile-shaped cardboards. If the patient has inversional or eversional deformity prior to the reduction, the fixation must be done in the position against the direction of the force which has caused the fracture, that is, eversional fixation for inversional fracture and vice versa. Moulding splints can also be used but their shapes must be inverted or everted so that they can embrace the malleoli and they must be put in right positions. And posterior, anteromedial and anterolateral splints are also used together, and tied up with laces. Mind that when the inversional fracture is fixed, the inferomedial pad should be thickened and when the eversional fracture is fixed, the inferolateral pad should be thickened. Finally, the fixation is done with an oo-shaped bandage. The fixation duration is 4 to 6 weeks.

Functional exercise:
In the early stage the shank is raised with the knee flexed at 600. The exercise is done on the activity of the toes and, to a certain extent, on the extensional activity of the ankle joint. In the case of bimalleolar fracture the exercise is intended to enlarge the scope of extending and flexing the ankle joint two weeks after the injury; and 4 to 5 weeks later, the fixation is removed and gradual increase in practice of Walking on the floor is needed. For those who have trimalleolar fracture and have been given traction treatment, more flexional and extensional exercises on the knee joint should be done. After the traction treatment is Stopped, splintage should be continued for two more weeks. And the patient should gradually increase the exercise of walking on crutches.

Herbal therapy  
Internal treatment based on syndrome differentiation  

1. In the early stage  
Main symptoms and signs:
Painful swelling in the ankle, thirst with bitter taste in the mouth, difficulty in urination and defecation.
 
Therapeutic methods:
Promoting blood flow to remove the stasis, relieving swelling to check pain.
 
Recipe and herbs:
Modified Quyu Zhitong Decoction. Specifically, Jiudanggui (Radix Angelicae Sinensis Praeparata ) 12 g, Jiuchishaoyao ( Radix Paeoniae Rubrae Praeparata )12 g, Honghua ( Flos Carthmi )9 g, Taoren (Semen Persicae) 9g, Zelan (Herba Lycopi Lucidi)9 g, Mutong (Caulis Akebiae)9 g, Chuanxiong  (Rhizoma Ligustici Chuanxiong)6 g, Sanleng (Rhizoma Sparganii Stoloniferi )6 g, Jiangxiang ( Lignum Dalbergiae Odoriferae )6 g, Yanhusuo (Rhizoma Corydalis )15 g, Chenpi ( Pericarpium Citri Reticulatae )9 g and Gancao (Radix Glycyrrhizae ) 9 g.
 
2. In the middle stage
Main symptoms and signs:
Alleviated swelling and pain in the ankle, unhealed fracture.
 
Therapeutic method:
Reuniting the bones, muscles and ligaments.
 
Recipe and herbs:
Modified Xinshang Xuduan Decoction. The herbs see the treatment of fractures of radial and ulnar shafts in the middle stage.

3. In the late stage
Main symptoms and sings:
Rigidity of the ankle with impaired movement and weakness in walking.
 
Therapeutic methods:
Relaxing tendons and removing obstruction from collateral.

Recipe and herbs:
Modified Huoxue Shujin Decoction. The herbs see the treatment of fracture of femoral shaft in the late stage.
 
External therapy:
In the early stage, Shuangbai powder or Sanse Application is externally used.In the middle stage, Jiegu Xujin Plaster is externally applied. In the late stage, fumigation and bathing of the affected part may be applied with Shujin Huoxue Lotion.Specifically, Shenjincao (Herba Lycopodii Japonici )9 g, Haitongpi ( Cortex Erythrinae )9 g, Qinjiao ( Radix Gentianae Macrophyllae)9 g, Danggui (Radix Angelicote Sinensis )9g, Duhuo (Radix Angelicae Pubescentis)9 g, Ruxiang ( Gummi Olibanum )9 g, Moyao (Myrrha)9g, Honghua (Flos Carthmi)9 g and Gouteng (Ramulus Uncariae cum Uncis)5 g. Give it 3 to 4 times daily.