Procedure-Specific Protocols
These are the specific recovery plans Dr. Williams uses for individual procedures. Open the one that matches your surgery. Always follow the instructions you were given after your procedure — if anything here differs, those come first.
Trimalleolar Ankle Fracture
About your surgery
A trimalleolar ankle fracture involves breaks in all three parts of the ankle joint: the medial malleolus (the bony bump on the inside of your ankle), the lateral malleolus (the bony bump on the outside), and the posterior malleolus (the back edge of the shinbone). When all three break, the ankle joint becomes very unstable and can dislocate. This type of fracture almost always requires surgery.
The fracture is fixed by open reduction and internal fixation (ORIF): the bone fragments are repositioned anatomically and held in place with plates, screws, or a combination of both. The hardware is designed to stay in permanently unless it becomes symptomatic, in which case removal can be discussed at a later visit.
Recovery takes longer than many patients expect. The ankle mortise must heal completely before weight bearing is safe — loading the ankle too early risks hardware failure or malunion. Following the protocol carefully is the most important thing you can do to protect your repair.
Recovery timeline
| When | What to expect | Weight bearing |
|---|---|---|
| Surgery day | Robert Jones splint applied. Rest, ice behind the knee, elevate the leg. The nerve block typically wears off 12–24 hours after surgery — start your pain medication before it does, rather than waiting for pain to build. | None — crutches or knee scooter |
| 2–6 weeks | Splint off, sutures removed, X-rays taken. Transition to CAM boot. Physical therapy begins. Work on ankle range of motion. Boot can be off for sleeping. | Non-weight bearing in boot |
| 6 weeks | Weight-bearing X-rays. Begin loading the ankle in the boot. | Start progressive weight bearing in CAM boot |
| 8–10 weeks | Progress from the boot to an ASO brace and a regular shoe over 1–2 weeks. Non-impact activity as tolerated (walking, bike, elliptical). | Full weight bearing |
| 10–12 weeks | Gait normalization and balance training. Slowly return to activities as tolerated. | Unrestricted |
| 4–6 months | Return to all activities as tolerated. Return-to-sport assessment if applicable. If a syndesmotic screw was placed, it can be removed at 4 months. All other hardware can be removed at around 1 year if it becomes symptomatic. | Unrestricted |
Mobility aids
Robert Jones splint (surgery day through 2 weeks). A thick, well-padded plaster splint applied in the operating room. It is not waterproof — keep it completely clean and dry. It will be removed at your 2-week visit when you transition to the CAM boot.
Crutches. Try to obtain these before your surgery date, though they can also be provided at the hospital. Keep all weight off the surgical leg. Crutch tops should sit 1–2 inches below your armpits — never rest your full weight on your armpits. On stairs: lead up with the good foot, lead down with the crutches (“up with the good, down with the bad”).
Knee scooter (recommended). Many patients find a knee scooter far easier than crutches, especially at home. Your shin rests on a padded platform while you push with the good leg. Always engage the brake when stationary. Available at most medical supply stores and pharmacies, often through insurance, and can be rented in clinic or after surgery.
Medications
Take medications as prescribed for you. Do not exceed the doses below. Acetaminophen is present in many combination products (including Percocet, Norco, and NyQuil) — check every label so you do not double up without realizing it.
| Medication | Dosing | Notes |
|---|---|---|
| Acetaminophen (Tylenol) 500 mg | Every 6 hours as needed | Do not increase this dose on your own. Never exceed 4,000 mg in 24 hours from all sources combined. |
| Ibuprofen (Advil/Motrin) 600 mg | Every 6–8 hours with food as needed | The aspirin or blood thinner listed below is not a reason to avoid ibuprofen — but do not take it if you were on a therapeutic-dose blood thinner before surgery, or if you have kidney disease, ulcers, or reflux. Ask if unsure. |
| Oxycodone / hydrocodone / Dilaudid | As prescribed, for breakthrough pain | Take with food. Do not drive. Wean off as quickly as tolerated. |
| Blood thinner (aspirin, Xarelto, Eliquis, or Lovenox) | As directed | For DVT prevention. Continue for 4 weeks after surgery, or until Dr. Williams tells you to stop. |
| Stool softener (docusate) and/or laxative (senna) | Daily while taking opioids | Opioid pain medication causes constipation in nearly everyone. Start this the day of surgery rather than waiting for a problem. Drink plenty of water. |
Wound care
- Steri-strips will be applied at your 2-week visit after your sutures are removed. Leave them in place until week 3, then remove them. If they fall off on their own before then, that is fine.
- Do not submerge the incision — no baths, pools, lakes, or hot tubs until the wound is fully healed.
- Showering is okay once the splint is removed. Letting water run over the incision is fine; do not scrub it. Pat the area dry afterward.
- Do not apply lotions, creams, or ointments to the wound unless specifically instructed.
- Watch for signs of infection: increasing redness, warmth, drainage, the wound opening, or a fever above 101.5°F. Call immediately if any of these occur.
Physical therapy
Physical therapy begins at your 2-week visit, once the splint is removed and you are in the CAM boot.
Weeks 2–6 — joint mobility phase (non-weight bearing)
- Full ankle and toe range of motion allowed
- Isometric exercises; swelling and pain management
- Non-weight-bearing strengthening of the hip and core
Weeks 6–10 — progressive weight bearing phase
- Progressive weight bearing in the boot, advancing to an ankle brace and shoe
- Ankle range of motion and strengthening
- Balance and proprioception training
- Gait normalization — walking mechanics are often significantly altered after a prolonged period of non-weight bearing
Weeks 10–12+ — strengthening and return to function
- Slowly advance activities as tolerated
- Cardio as tolerated: walking, stationary bike, elliptical
4–6 months — return to activity
- Return to all activities as tolerated
- Return-to-sport assessment if applicable
Driving and flying
Driving. Left foot surgery: you may begin driving when you are comfortable and off narcotic pain medication. Right foot surgery: when you are fully weight bearing, out of the boot, and off narcotics. Confirm with Dr. Williams before resuming either way.
Flying. Wait until you are fully weight bearing and out of the boot. Flying in a splint or while non-weight bearing carries an elevated risk of blood clots. If travel cannot wait, call the office first so we can discuss precautions.
Do’s and don’ts
| Do | Don’t |
|---|---|
| Elevate your leg as much as possible — less swelling means less pain | Put any weight on the foot until you are cleared — non-weight bearing means no weight at all |
| Ice behind the knee (not directly on the incision) for 20 minutes, several times per day | Soak, submerge, or get the incision wet — no baths, pools, or hot tubs until healed |
| Take pain medication as prescribed; call if your pain is uncontrolled | Take more than 4,000 mg of acetaminophen (Tylenol) in 24 hours from all sources |
| Wear your boot whenever you are up and moving; it can be off at night and when resting | Return to driving until you are specifically cleared by Dr. Williams |
| Keep the incision clean and dry until it is fully healed | Fly until you are fully weight bearing and out of the boot |
| Use crutches or a knee scooter for all mobility | Skip your blood thinner — it is preventing a clot even if you feel fine |
| Wear a compression stocking (20–30 mmHg) when upright, once the splint is removed at 2 weeks |
Common questions
Why can’t I bear weight yet?
The bone fragments must heal in the correct position before the joint can handle load. Bearing weight too early risks shifting the hardware, hardware failure, or the bones healing in a malaligned position — any of which can cause long-term arthritis or instability.
My ankle is very swollen. Is that normal?
Yes. Swelling after ankle ORIF is expected and can persist for 6 months to a year. Elevation is the single most effective thing you can do to reduce it, especially in the first 6 weeks. Swelling is a sign of ongoing healing, not a sign that something is wrong.
What are the signs of a blood clot (DVT)?
Calf pain, swelling in one leg, warmth, or redness in the calf. If you experience chest pain or shortness of breath, call 911 immediately — this may be a pulmonary embolism and is a medical emergency.
What is a syndesmotic screw?
The syndesmosis is the ligament connection between the two lower leg bones just above the ankle. It is sometimes torn along with a trimalleolar fracture and needs a screw to hold it while it heals. Dr. Williams will tell you if you have one. If so, it can be removed at around 4 months.
Will the hardware need to come out?
The plates and screws can stay in permanently without issue. However, if hardware becomes painful or prominent, it can be removed around a year from surgery. Recovery from removal is usually immediate weight bearing without restrictions.
When can I soak in a bath or hot tub?
Not until your incision is fully healed — typically 4–6 weeks from surgery. We wait until there is no scabbing and the skin is fully intact.
Can I drive?
Left foot surgery: once you are comfortable and off narcotic pain medication. Right foot surgery: when you are fully weight bearing, out of the boot, and off narcotics. Confirm with Dr. Williams before resuming.
Call 911 or go to the emergency room immediately if you experience chest pain, shortness of breath, calf pain with swelling, a fever above 101.5°F, or the wound opening or draining.
General Post-Operative Instructions
- Your doctor will provide specific instructions based on the type of surgery you have undergone. The guidelines below outline general care recommendations that apply to most surgical procedures.
- Take prescribed pain medications and other medications exactly as directed. Pain medication should be taken with food. After the first 48 hours, use pain medication only as needed.
- Do not drink alcohol, drive, operate machinery, or sign legal documents for at least 24 hours after surgery. Sedatives or anesthesia used during the procedure may continue to affect judgment and reaction time during this period.
- Use ice packs to help reduce swelling. Be sure the ice does not leak into the surgical dressing. Ice may be applied frequently during the first 48 hours and continued afterward if swelling persists.
- Follow all activity restrictions provided by your doctor. Rest for the first few days after surgery and keep the operated limb elevated above heart level whenever possible to help control swelling. Preventing pain is easier than treating it once it develops.
- Keep the surgical dressing clean and dry to promote proper wound healing.
- Physical therapy is often started within a day or two after surgery, unless otherwise instructed. Early exercises usually focus on restoring joint motion, with strengthening exercises added later. Consistent participation in therapy is essential for optimal recovery.
- Maintain a healthy diet and drink plenty of non-alcoholic, non-caffeinated fluids to support healing.
- Be sure to schedule and attend your follow-up appointment as directed by your doctor.
Please consult your doctor immediately if you experience any of the following symptoms:
- Increased drainage from the incision
- Increased redness around the operated area
- Increased swelling that does not decrease with ice and elevation
- Foul odor
- Fever greater than 101°F
- Coldness, numbness, or blanched white or bluish color of the fingers or toes
- Sudden calf pain or shortness of breath
- Chest pain
