A trimalleolar fracture represents a severe injury to the ankle joint, involving breaks in three distinct areas of the tibia and fibula bones. This complex damage almost always necessitates open reduction with internal fixation (ORIF) surgery to restore the joint’s stability and function. The outcome of this procedure is a surgical scar, or often multiple scars, that serves as a permanent marker of the injury. Understanding the location, expected appearance, and management techniques for this post-operative mark is key to managing expectations and achieving the best possible cosmetic and functional result.
The Location and Initial Look of the Scar
The surgical repair of a trimalleolar fracture typically requires incisions on both the inner and outer sides of the ankle to access the damaged bones. The lateral malleolus, the prominent bone on the outside of the ankle, is accessed via a vertical incision along the fibula. A separate incision is often made on the inside of the ankle to address the medial malleolus, the bony prominence of the shinbone. The posterior malleolus, located at the back of the tibia, may require a third incision, depending on the fracture’s severity.
In the initial weeks following surgery, the scar will appear as a raised, bright red or pink line, which is a normal part of the inflammatory healing phase. The skin around the incision sites is often swollen and firm due to the underlying trauma and the surgical manipulation required to place plates and screws. As the sutures or staples are removed, the area may feel tight, itchy, or tender to the touch, but this immediate appearance is a temporary stage of healing.
The Process of Scar Maturation
Scar maturation is a dynamic and long-term biological process divided into several overlapping phases. After the initial inflammatory stage, the proliferative phase begins, where specialized cells called fibroblasts produce collagen to form a new tissue bridge across the wound. This collagen is initially laid down quickly and without much organization, leading to the raised, firm texture characteristic of an immature scar.
The final and longest phase is remodeling, which can take between 12 and 24 months to complete. During this period, the collagen fibers are reorganized and realigned, replacing the temporary, weaker collagen with stronger, more structured fibers. The scar tissue’s vascularity decreases, causing the color to fade gradually from a vibrant red or purple to a softer pink, eventually becoming a flat, pale line. Patience is necessary as the final appearance cannot be accurately judged until this maturation is complete.
Essential Home Care for Optimal Healing
Once the incision is fully closed and cleared by the surgical team, typically around two to four weeks post-surgery, active home management can begin. Scar massage is recommended to help flatten and soften the developing tissue by promoting collagen remodeling. Using the fingertips, firm but comfortable pressure should be applied in circular, horizontal, and vertical motions along the length of the scar for about five minutes, two to three times per day.
Silicone therapy is a well-supported method for improving scar appearance, working by hydrating the upper layer of the skin and regulating collagen production. Silicone sheets or gels should be worn over the scar for up to 12 hours a day for several months. Protecting the new scar from ultraviolet (UV) radiation is important, as the fragile tissue is highly susceptible to sun-induced hyperpigmentation, which can cause the scar to darken permanently. Covering the scar with clothing or using a broad-spectrum sunscreen with an SPF of 30 or higher is necessary whenever the ankle is exposed to sunlight for at least the first year.
Recognizing and Treating Scar Complications
While most surgical scars fade and flatten over time, some may develop into abnormal healing patterns, primarily hypertrophic scars or keloids. A hypertrophic scar is characterized by a raised, thickened, and often itchy appearance, but it remains confined within the boundaries of the original surgical incision. These scars are common on areas of high skin tension, like the ankle, and they may spontaneously improve over many months or years.
A keloid scar is a more aggressive form of excessive tissue growth that expands beyond the borders of the initial wound into the surrounding healthy skin. Unlike hypertrophic scars, keloids rarely regress naturally and are generally more challenging to treat. If home care methods are insufficient, professional interventions can be sought from a dermatologist or plastic surgeon.
Medical Treatments
Medical treatments often begin with corticosteroid injections directly into the scar tissue to reduce inflammation and break down excess collagen. Other options include laser therapy, which can target the redness and texture of the scar, or cryotherapy, which involves freezing the tissue.
Surgical Options
Surgical revision may be considered in some instances. However, this is often combined with other therapies to minimize the risk of the abnormal scar reforming.