Fibula: External fixation of the fibula is not indicated despite any amount of associated tibia or soft tissue injury.

Ankle: To stabilize the ankle (typically in the setting of an unstable distal tibia fracture), two pins should be placed in the tibia proximal to the fracture site and be connected to a centrally-threaded transfixation pin (or pins) placed through the calcaneus using a medial-to-lateral approach to avoid injury to the neurovascular bundle located just posterior to the medial malleolus. (Figure 4a below) While a 4 mm pin can be placed in the first metatarsal to control ankle dorsiflexion, stable placement can be difficult and the tibialis anterior tendon at the base of the bone can be at risk. A calcaneal pin is more easily placed, and sufficient ankle dorsiflexion can be maintained with the addition of a posterior slab splint as necessary. Talar neck pins, with appropriate anatomic knowledge, can be useful to stabilize the distal tibia, particularly if a calcaneal fracture is present that precludes transfixation pin placement.