Ankle fracture is common in active young males. Treating ankle fractures can be straightforward or much more complicated; treatment options include nonoperative management or open anatomical reduction with rigid internal fixation. Successful treatment will allow early mobilization to avoid complications. Inadequate treatment, either nonoperative or operative management, may result in malunited ankle fractures. However, malunited ankle fractures due to the delayed presentation are very rare. An 18-year-old male presented to the clinic with a history of twisting injury to his right ankle two years ago. The patient sought medical advice once after injury, applied a back slab, and was advised for operative intervention. He refused the surgical intervention and was lost in follow-up. After two years, he presented again with ankle deformity and swelling. Assessment at initial presentation includes fibula malunion, medial malleolus malunion, and widening of the ankle mortise with talar tilt. Fogel and Morrey's performance index was used to evaluate the biomechanical result postoperatively. Delayed open anatomical reduction and rigid internal fixation of malunited ankle fractures to achieve normal ankle alignment will delay the onset of future degenerative changes and minimize the chance for early arthrodesis.

Mousa Mohammed Thalth Alhaosawi is a distinguished orthopaedics surgeon with over 21 years of experience. He is currently practicing at King Salman Medical City in the Kingdom of Saudi Arabia, where he provides advanced care in the field of orthopaedics.