The Physician and Sportsmedicine
Menubar Home Journal Personal Health Resource Center CME Advertiser Services About Us


A 'Three-Way' Splint for Acute Ankle Injury

Michael J. Petrizzi, MD; Mark G. Petrizzi, MD; Allen Miller
Department Editor: William O. Roberts, MD


Acute ankle injuries are among the most commonly seen sports-related injuries in primary care. Many of these are simple lateral sprains, for which immobilization is typically not appropriate because it tends to prolong rehabilitation. However, immobilization is often indicated for more severe ankle injuries. These are usually accompanied by a large amount of edema, which precludes immediate casting. In such cases, a "three-way" ankle splint will provide excellent interim immobilization.

The three-way splint is appropriate for stable, nondisplaced distal fibular avulsion fractures, trimalleolar fractures awaiting surgery, and high (syndesmosis) sprains. The splint provides immobilization during the first 1 to 3 days after injury, while the patient uses RICE (rest, ice, compression, and elevation of the affected foot above the heart) to reduce edema and prepare the lower leg for cast application or other definitive care.

Examination of the Ankle

With every ankle injury, it is critical to perform a thorough physical examination including radiographic studies, if warranted. The Ottawa ankle rules (1) provide an excellent guideline regarding the need for x-rays in patients older than 18.

Physical evaluation should include careful examination and palpation of the lateral and medial malleoli and palpation of the navicular and lateral collateral ligaments, deltoid ligament, syndesmosis, proximal end of the fifth metatarsal, and entire length of the fibula and tibia.

In the case of a stable, nondisplaced distal fibular avulsion fracture, tenderness will be found over the lateral malleolus of the affected ankle, thereby mandating x-rays and precluding stress testing. Trimalleolar fracture involves both malleoli and the posterior portion of the tibial plafond. In a syndesmosis injury, the patient typically has tenderness over the anterior inferior tibiofibular ligament, often extending up the interosseous membrane, and pain with passive dorsiflexion and external ankle rotation.

Constructing the Splint

The three-way splint can be fabricated quickly and easily with a few orthopedic supplies. Before starting, be sure to have the necessary materials on hand: prefabricated splinting material wide enough to completely cover the bottom of the foot, one to two rolls of cast padding and elastic wrap of the same width, bandage scissors, gloves, a cast bucket, and 6-in. elastic wrap to hold the splint on. We use splint material that has seven layers of fiberglass with a layer of padding on each side to protect the skin from irritation.

Position the ankle in 0° of plantar flexion and dorsiflexion with no inversion, eversion, supination, or pronation. It is helpful to flex the knee to 90° to maintain this neutral ankle position during application of the splint.

Begin by applying cast padding to the affected ankle (figure 1: not shown). The bony prominences of both malleoli can lead to difficulty in minimizing the accumulation of edema. Cast padding can be used to "fill in the gaps" around the malleoli. We have not found it necessary to taper the edges of the padding, but it is important to keep the padding smooth. If the patient has an injury to the anterior talofibular ligament, the padding can be extended to the dorsum of the foot.

To prepare the splint, measure two pieces of the prefabricated splinting material, the same width as the cast padding used previously. One of these—the posterior splint (figure 2: not shown)—should be measured along the posterior lower leg, to reach from approximately four finger widths below the patient's fibular head to the distal metatarsal fat pads.

The other piece should reach from two finger widths below the fibular head, down around the heel, and up the medial leg to the same level as the other side, forming a sugar tong splint. Cut a piece of the fiberglass that is the width of the posterior splint out of the sugar tong at the heel. This will reduce the thickness of the splint in that area. Be sure to leave the lining intact to keep the splinting material in one piece.

Dip the posterior splint in lukewarm water, squeeze out the excess, and apply it to the posterior lower leg. Secure the splint with a single layer of cast padding, then an elastic wrap, winding from the distal end of the splint and overlapping 50%, rolling to the top (figure 3: not shown).

Dip the sugar tong portion in water, squeeze out the excess, and apply it so that the two pieces of splint are aligned on either side of the lower leg, reaching from the base of the heel to a point two finger widths below the fibular head (figure 4: not shown). Have the patient or an assistant hold it in place. Then secure the entire splint with a 6-in. elastic wrap, which can assist in molding the splint around the malleoli to help decrease edema formation.

Instruct the patient to hold the affected foot and ankle in a neutral position as the splint dries. Movement during the drying process may significantly weaken the splint.

Take-Home Instructions

The patient should be instructed not to remove the splint and to follow up in 24 to 48 hours, when it's likely a cast will be applied. When the patient showers, the affected leg should be held outside the bathtub or shower or covered with a plastic bag secured at the top with rubber bands or tape.

Give the patient appropriate crutches and crutch training, with instructions to follow the RICE protocol until the follow-up appointment. The patient should also be given a cast and splint care sheet, with instructions to return to the office or emergency department if signs of neurovascular compromise are noted.

If cared for properly, these three-way splints can last 2 weeks, but patients won't likely need them that long.


  1. Stiell IG, McKnight RD, Greenberg GH, et al: Implementation of the Ottawa ankle rules. JAMA 1994;271(11):827-832

Dr Michael Petrizzi is director of the family practice residency program and Dr Mark Petrizzi is on the residency program faculty at Hanover Family Physicians in Mechanicsville, Virginia. Mr Miller is a certified orthopedic technician at the UCLA Medical Center in Los Angeles.