Approach

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][20]​ There may be an obvious deformity to the ankle.[19]

On palpation there will be tenderness over the medial or lateral malleolus, possible deformity to the ankle, and crepitus with range of motion.[21]​ 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]

Tenderness of the proximal fibula may signify fracture and possibly the Maisonneuve fracture pattern (disruption of the tibiofibular syndesmosis).[1]

Open fractures may occur.[8]​ 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]

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]

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]

Radiology

Ottawa ankle rules have been developed to help decide when to order x-rays.[26][27]​ 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][27]​ 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][19]​​[28]​ 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][29]

MRI studies have suggested that transsyndesmotic or suprasyndesmotic fractures may both be associated with syndesmosis disruption.[30]

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][32]

A CT scan of the distal tibia and hindfoot is indicated for the assessment of comminuted fractures, particularly those involving the posterior malleolus.[7][33][34]​​ CT is used to assess for impaction; delineate all fracture components; and to aid preoperative planning.[35][36] The American College of Radiology recommends that MRI of the ankle may be appropriate for some patients with acute trauma.[36] 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]

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