Generally ankle fractures in the very elderly are treated by non-operative methods but some fractures can be highly unstable and are difficult to treat in a plaster.

During a 10-year period, 74 patients over the age of 70 years were retrospectively studied to identify the early complications, length of stay, return to pre-injury mobility and residential status. There were 58 females and 16 males with an average age of 76 years (70–91years). 57(77%) fractures were at the level of the syndesmosis (Type B) and 17(33%) were above the level of the syndesmosis (Type C). All but one injury was due to a simple fall. All patients had initial manipulation and plaster immobilisation. They underwent ORIF after the reduction in the plaster was lost. Plate and screws were used in 53 patients (72%), rush pins in 12 patients (16%) and external fixation was used in 2 patients. All patients were immobilised in a below knee plaster after surgery for 6–8 weeks.

Following surgery, 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality were recorded. In 12% of patients, soft bone and communition precluded fixation of one malleolus. The average length of stay for patients who walked with a Zimmer frame before injury was significantly longer than for those who walked independently or with sticks. However, the majority (85%) of patients regained their pre-injury mobility and residential status.

We conclude that ORIF of ankle fractures in the elderly carries a significant risk of wound edge necrosis with delayed wound healing but the incidence of deep infection is relatively low. ORIF should be reserved for patients where non-operative management has failed. Poor bone quality presents technical difficulties but the majority of patients can expect a good outcome.