Often there is history of a slip, fall, or other trauma with an inability to weight-bear. Patients may describe a sound with giving way of the ankle. They may have immediate pain over either the medial or lateral malleolus or both.
Physical examination
Inspection of the ankle may reveal swelling and ecchymosis around either the medial or lateral malleolus or both.[19]Kyriacou H, Mostafa AMHAM, Davies BM, et al. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract. 2021 Nov;31(11):427-34.
https://journals.sagepub.com/doi/full/10.1177/1750458920969029
http://www.ncbi.nlm.nih.gov/pubmed/33826430?tool=bestpractice.com
[20]Larkins LW, Baker RT, Baker JG. Physical examination of the ankle: a review of the original orthopedic special test description and scientific validity of common tests for ankle examination. Arch Rehabil Res Clin Transl. 2020 Sep;2(3):100072.
https://www.archives-rrct.org/article/S2590-1095(20)30039-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/33543095?tool=bestpractice.com
There may be an obvious deformity to the ankle.[19]Kyriacou H, Mostafa AMHAM, Davies BM, et al. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract. 2021 Nov;31(11):427-34.
https://journals.sagepub.com/doi/full/10.1177/1750458920969029
http://www.ncbi.nlm.nih.gov/pubmed/33826430?tool=bestpractice.com
On palpation there will be tenderness over the medial or lateral malleolus, possible deformity to the ankle, and crepitus with range of motion.[21]Coleman N. General fracture considerations. Curr Sports Med Rep. 2018 Jun;17(6):175-6.
https://journals.lww.com/acsm-csmr/fulltext/2018/06000/general_fracture_considerations.2.aspx
In the case of potential isolated lateral malleolar fractures, physical exam findings such as tenderness, ecchymosis, and swelling about the deltoid are poor predictors of deltoid integrity.[22]van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2009;129:227-235.
http://www.ncbi.nlm.nih.gov/pubmed/18953550?tool=bestpractice.com
Tenderness of the proximal fibula may signify fracture and possibly the Maisonneuve fracture pattern (disruption of the tibiofibular syndesmosis).[1]Inokuchi R, Jujo Y, Iwashita K, et al. Maisonneuve fracture: a type of ankle fracture. BMJ Case Rep. 2019 Nov 4;12(11):e231961.
https://casereports.bmj.com/content/12/11/e231961.long
Open fractures may occur.[8]Simske NM, Audet MA, Kim CY, et al. Open ankle fractures are associated with complications and reoperations. OTA Int. 2019 Dec;2(4):e042.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997115
http://www.ncbi.nlm.nih.gov/pubmed/33937670?tool=bestpractice.com
While the open injury may occur at any place, usually it is a transverse open injury over the medial malleolus with posterolateral displacement of the talus and foot.
If there is a dislocation there may be tenting of the skin over the medial malleolus.[23]Lawson KA, Ayala AE, Morin ML, et al. Republication of "ankle fracture-dislocations: a review". Foot Ankle Orthop. 2023 Aug 12;8(3):24730114231195058.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10423454
http://www.ncbi.nlm.nih.gov/pubmed/37582190?tool=bestpractice.com
Vascular compromise is rare and is usually the result of fracture-dislocations. Neurovascular status should be assessed using hard signs (lack of palpable pulse, continued blood loss, or expanding hematoma). Assessment should not rely on capillary return or Doppler signal to exclude vascular injury.[24]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. Nov 2022 [internet publication].
https://www.nice.org.uk/guidance/ng37
If the ankle fracture is due to high-energy trauma it is important to follow the Advanced Trauma Life Support recommended principles when evaluating the patient.[25]Advanced Trauma Life Support (ATLS): Student Course Manual. 10th ed. Chicago (IL): American College of Surgeons; 2018.
Radiology
Ottawa ankle rules have been developed to help decide when to order x-rays.[26]Milne L. Ottawa ankle decision rules. West J Med. 1996;164:67.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303302/pdf/westjmed00352-0069.pdf
[27]Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-32.
http://www.ncbi.nlm.nih.gov/pubmed/8433468?tool=bestpractice.com
Ankle x-rays should be ordered if there is posterior lateral or medial bony tenderness within 6 cm of the distal aspect of the fibula or tibia or an inability to weight-bear four steps at the scene or in the emergency department.[26]Milne L. Ottawa ankle decision rules. West J Med. 1996;164:67.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1303302/pdf/westjmed00352-0069.pdf
[27]Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269:1127-32.
http://www.ncbi.nlm.nih.gov/pubmed/8433468?tool=bestpractice.com
Ankle fractures are diagnosed mainly from plain radiographs in orthogonal planes: usually an anteroposterior or mortise view (15° internal rotation of the ankle) and a lateral radiograph.[7]British Orthopaedic Association Standards for Trauma. The management of ankle fractures. Aug 2016 [internet publication].
https://www.boa.ac.uk/static/f8b1c499-c38a-4805-8cb8d8eb3087bca7/8be763eb-5921-4cb2-b6802f3e65ce8e7f/the%20management%20of%20ankle%20fractures.pdf
[19]Kyriacou H, Mostafa AMHAM, Davies BM, et al. Principles and guidelines in the management of ankle fractures in adults. J Perioper Pract. 2021 Nov;31(11):427-34.
https://journals.sagepub.com/doi/full/10.1177/1750458920969029
http://www.ncbi.nlm.nih.gov/pubmed/33826430?tool=bestpractice.com
[28]Vangsness CT Jr, Carter V, Hunt T, et al. Radiographic diagnosis of ankle fractures: are three views necessary? Foot Ankle Int. 1994 Apr;15(4):172-4.
http://www.ncbi.nlm.nih.gov/pubmed/7951949?tool=bestpractice.com
External oblique views may be taken; however, they rarely add significant information.
In the case of isolated lateral malleolar fractures, if there is lateral talar shift of ≥5 mm (i.e., medial malleolar-talar clear space), then a concomitant injury to the deltoid ligament is associated.[22]van den Bekerom MP, Mutsaerts EL, van Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2009;129:227-235.
http://www.ncbi.nlm.nih.gov/pubmed/18953550?tool=bestpractice.com
[29]Park SS, Kubiak EN, Egol KA, et al. Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements. J Orthop Trauma. 2006;20:11-18.
http://www.ncbi.nlm.nih.gov/pubmed/16424804?tool=bestpractice.com
MRI studies have suggested that transsyndesmotic or suprasyndesmotic fractures may both be associated with syndesmosis disruption.[30]Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. 2005;436;216-221.
http://www.ncbi.nlm.nih.gov/pubmed/15995444?tool=bestpractice.com
With isolated lateral malleolar fractures, stress radiographs (external rotation or valgus stress) or a standing anteroposterior radiograph of the ankle may reveal talar shift and concomitant damage to the deltoid ligament.[31]Schock HJ, Pinzur M, Manion L, et al. The use of gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br. 2007;89:1055-1059.
http://www.ncbi.nlm.nih.gov/pubmed/17785745?tool=bestpractice.com
[32]Koval KJ, Egol KA, Cheung Y, et al. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report. J Orthop Trauma. 2007;21:449-455.
http://www.ncbi.nlm.nih.gov/pubmed/17762475?tool=bestpractice.com
A CT scan of the distal tibia and hindfoot is indicated for the assessment of comminuted fractures, particularly those involving the posterior malleolus.[7]British Orthopaedic Association Standards for Trauma. The management of ankle fractures. Aug 2016 [internet publication].
https://www.boa.ac.uk/static/f8b1c499-c38a-4805-8cb8d8eb3087bca7/8be763eb-5921-4cb2-b6802f3e65ce8e7f/the%20management%20of%20ankle%20fractures.pdf
[33]Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J. 2017 Nov;99-B(11):1413-9.
http://www.ncbi.nlm.nih.gov/pubmed/29092978?tool=bestpractice.com
[34]Stringfellow TD, Walters ST, Nash W, et al. Management of posterior malleolus fractures: a multicentre cohort study in the United Kingdom. Foot Ankle Surg. 2021 Aug;27(6):629-35.
http://www.ncbi.nlm.nih.gov/pubmed/32878722?tool=bestpractice.com
CT is used to assess for impaction; delineate all fracture components; and to aid preoperative planning.[35]Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment. EFORT Open Rev. 2018 May;3(5):294-303.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994620
http://www.ncbi.nlm.nih.gov/pubmed/29951269?tool=bestpractice.com
[36]American College of Radiology. ACR appropriateness criteria: acute trauma to the ankle. 2020 [internet publication].
https://acsearch.acr.org/docs/69436/Narrative
The American College of Radiology recommends that MRI of the ankle may be appropriate for some patients with acute trauma.[36]American College of Radiology. ACR appropriateness criteria: acute trauma to the ankle. 2020 [internet publication].
https://acsearch.acr.org/docs/69436/Narrative
However, although MRI examination may be helpful in determining articular damage and ligamentous injury, it is rarely used in practice for diagnosis or management of an acute injury.[30]Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. 2005;436;216-221.
http://www.ncbi.nlm.nih.gov/pubmed/15995444?tool=bestpractice.com